HOSPITALS FOR THE SICK
Two Basic Problems
How did the war, as a whole, affect the position of the sick population of men, women and children who needed treatment in hospital? What was the price of the success achieved by the emergency medical scheme and who paid it These two questions form the main theme of this concluding chapter on hospital service in wartime. The answer to one is closely bound up with the answer to the other.
The influence of the emergency scheme on the day-to-day work of the nation's hospitals went far beyond the limits of its own particular field of action. To judge the scheme on its operations within these limits would be to ignore, therefore, the fact that it 'became in effect the wartime treatment of the whole hospital problem'.1 Whatever the nature of the action take by the Ministry of Health—the reservation or dereservation of beds, the provision of new services or the curtailment of existing ones—it could not fail to affect all hospital users either directly or indirectly. The victims of enemy air attack and the victims of disease used the same hospitals. Many of the improvements introduced by the emergency scheme could not be restricted to particular groups of patients, and in varying degrees they all profited. But because there were not enough beds in the hospitals to meet all demands, priority for one group could only be established at the expense of another. This was one of the two basic problems which faced the Ministry throughout the war. The other arose from the contradictions between great responsibilities and limited powers.
The Ministry was expected, in fact, to do the impossible. Even before the war the hospitals of the country had been unable to meet all demands and the service provided had not been of a uniformly good standard. Now these hospitals were asked to carry a double burden and to improve the quality of their work as well. When they were mobilised for war, they had to prepare for risks unknown in size and time, keeping vacant and ready large number of beds. Waste of resources on a big scale had to be accepted as an inevitable corollary of war. At the same time, the ordinary sick needed hospital treatment
as usual. All subsequent improvements, extensions and efforts to rationalise hospital organisation were insufficient to bridge the gap between what was needed was what was available. Somebody had to pay the price of war by going without, waiting longer, getting less or being pushed about to make room for others. Aid raid casualties and men and women in uniform had first claim upon the hospitals. Every practical, political and psychological consideration supported that claims. Those who suffered hardship were the civilian, and among those who suffered most were the poorest, the most helpless and the 'useless' members of the community.
This conflict over needs and resources lasted all through the war. In a number of instances it was resolved for some people by accepting into the emergency scheme particular groups of patients. But the large mass of the civilian population remained outside. They had no claims upon the scheme, and if some of the benefits of the scheme came their way it happened incidentally and not by design. The Ministry could not, however, disregard the pressure of the civilian sick upon the country's hospital accommodation nor did it wish to do so. At certain critical stages of the war this pressure exercised a direct influence upon policy, and it never ceased to be a source of embarrassment and strain.
The Ministry had to grapple with these responsibilities without interfering either with the ownership or the administration of hospitals. The emergency scheme was regarded as something provisional and temporary, a wartime expedient created for a defined purpose, designed and conducted in such a way that the status quo in the hospital world would be maintained along with all existing rights, privileges and interests. Each component part of the scheme remained an independent unit, responsible only to its own board or its own council. the result was a loosely knit organisation, aiming at being a national hospital service for a particular emergency purpose only, and consisting of hospitals averse from change, jealous of their rights and more accustomed to competition than cooperation. By rendering great material assistance to hospitals, the Ministry could help to remove deficiencies and improve services, but it could not eliminate all the contradictions in organisation and function.
To achieve its purposes under such conditions, the Ministry had to be guided in its actions not by what it was legally permitted to do but by what was politically expedient and practically possible. Legally, its powers under the Defence Regulations were wide;2 in practice
they had to be exercised with great caution and tact. Legally, the Ministry could issue formal direction to hospitals, but in practice it had to refrain from doing so. In all its dealings with hospitals it had to take into account the susceptibilities and interests of the two different types of hospitals—the voluntary group and the public group.
In this field of hospital service, as everywhere else, the national discipline imposed by the war produced more unity and willingness to cooperation than existed in normal times. But in its day-to-day work the Ministry needed some means by which its decisions might be enforced, and this it derived only indirectly from its material assistance to hospitals, and from the national control of manpower, materials and transport. In almost all its measures of policy,. whether they concerned the increase or decrease of bed reservations, the admission or transfer of various groups of patients, or the food and welfare services in hospitals, the Ministry had to suggest and negotiate rather than instruct. In doing so, it was expected to take into account not only the operational needs of the emergency scheme but the interests—and sometimes the long-term interests—of the hospitals concerned. The finance of voluntary hospitals, for instance, was at the root of many difficulties which arose when decisions had to be made and policies shaped.
These circumstances explain, more than anything else, the slow pace at which the emergency scheme adapted itself to new situations.3 Long negotiations and much diplomatic ingenuity were necessary when everything cried for prompt action. The Ministry could not act quickly; all it could do was to remove obstacles and propose remedies and hope that the hospitals themselves would act.
This is where the two main problems which faced the Ministry are linked together. The double burden placed upon inadequate hospital systems and the limited authority of the central department to make the fullest possible use of all available resources—these two factors are the key to understandings the social history of the emergency medical service.
The Position of the Civilian Sick
How did the Ministry and the hospitals approach the problem of the needs of sick civilians during the years of the war? For the Ministry, the experience of 1939 had been an important lesson. The almost
complete disregard of ordinary civilian needs during the first weeks of war caused much hardship, and it had not proved possible to keep all the sick out of the hospitals for long. They were a part of the 'home front', and their circumstances could not be separately considered and regarded as something apart from the general hospital situation.
It was of course easier to curtail the civilian services than to re-establish them, but by the time heavy bombing began after a year of war many of the early restrictive measures had been lifted. The position of the civilian sick, however, greatly worsened by the direct and indirect effects of the raids, and in December 1940 the Ministry issued an appeal to hospitals to do as much civilian work as possible.4 By this time, many more complaints were reaching the Ministry. They recorded the detail of individual tragedies which were not exceptional but symptomatic of the general situation. These complaints, some publicly stated, aroused compassion, for the war had not altered the standards of ordinary humanity among the people. The Ministry, sensitive to parliamentary and public criticism, tried to help when it was approached.5 It was anxious to show that the emergency scheme had not prevented civilians from getting hospital treatment. The reservation of beds, it always argued, was not a rigid arrangement; the beds could be used for people who really required them.
What the hospitals performed did not, however, necessarily agree with what the Ministry proposed. Evidence accumulated that many hospitals and doctors went further than the Ministry wished them to go.6 Civilian patients were refused admission while casualty beds remained unoccupied. The 'urgency' of a 'case' was defined in the strictest sense.7 General practitioners refrained from referring patients to hospital because they were under the impression that admission could be obtained only if it were a matter of life or death. Some evidence of this state of affairs was in the Ministry's postbag; some
was recorded in the reception wards of public hospitals which were filled to overflowing.
By the end of 1940 the Ministry was worried by the rising volume of complaints. The events of the winter and spring of 1940–1 in London (described in earlier chapters) did nothing to arrest the trend. It was, in all the circumstances, inevitable that sick civilians should be the first to go short. Every measure to provide for the needs of air raid casualties and Service patients indirectly deprived other claimants. This was certainly not the Ministry's with, but it was a logical consequence of the conditions created by war. In addition, the Ministry's financial arrangements with the voluntary hospitals discouraged the extension of civilian work. In its relationship with the Red Cross auxiliary hospitals various factors operated in the same direction. Beds stood empty waiting for casualties while waiting lists grew. There was only one type of institutions upon which sick civilians still had a formal claim—the public hospital. But the demand for beds was far too great to be met by this branch of the hospital service alone.
The flow of patients into and out of all hospital was determined by written and unwritten priorities. Some people got little or nothing; others received what they needed or even more. Among the four main groups of patients who competed for hospital care, the aged and chronic sick were the least favoured. The fact that they needed beds for long periods, and they they were not likely to be 'useful citizens' again, were two reasons why they were placed at the end of the queue. The second least favoured group included all other civilians who had not claims on the emergency medical service. They were ordinary sick people, men, women and children suffering from acute conditions, or they were expectant mothers in need of maternity beds. Their position was somewhat better than that of the aged and chronic sick. Hospitals took them more readily because their stay was not likely to be long. They were less helpless, more inclined to defend their claims, and they could get a hearing more easily because most of them were likely to be 'useful' again after recovery.
A third group, smaller in number, were the 'civilian E.M.S. patients', comprising air raid casualties, the 'transferred sick', certain industrial workers, evacuated mothers and children and others. In terms of priority, these people were the privileged group among victims or war workers. Finally, there were the Service patients, the most favoured group of all, who got the lion's share of hospital care throughout the war.
The emergency medical service tried to distinguish between the first two groups which were not its concern and the second two groups which were its responsibility. But the Ministry of Health, at the head
of the service, found it difficult to maintain the distinction. As the department charged with watching over the state of the nation's health it had to consider everyone—the not-so-favoured as well as the favoured. It was in the centre of the conflict between the needs, claims and interests of all groups of sick and injured people. For social, political and financial reasons it wanted the hospitals to treat as many civilians as possible. Yet it was the target of all the complaints, and it accepted the role of mediator in all disputes. Thus the Ministry, for the first time in its history, found itself acting as the principal champion of sick people in need of hospital care.
The Price Paid
It has been shown that the emergency medical service only achieved its success at a price, and that price was primarily paid by sick civilians. There remains the much harder task of assessing the amount of the price. The difficulty is, however, that no comprehensive figures exist. It is not easy to estimate what the hospitals did during the war; it is impossible to find out exactly what they could not do or failed to do. Waiting lists, for instance, even when they are available provide only a rough guide, for many people do not get on them. Who are these recorded and unrecorded people, and how many of them were there? How many were admitted to hospital only after serious delays? How many were discharged before they should have been? How many failed to secure a bed on a first-class hospital and had to be satisfied with lower standards? In short, how many people got less than they needed or got it too late or got nothing at all because the hospitals were mobilised for war?
No conclusive answers can be given to these questions. The picture that emerges from a study of all the facts that have been brought together is a mosaic, consisting of scraps of information from individual hospitals and regional offices, stories of hardship extracted from ministerial files, reports from local authorities, scattered inquiries into waiting lists, and facts drawn from the Hospitals Year Book and other published material. The results are impressive though they cannot satisfy the demands of statistician.
The complaints received by the Ministry of Health represent, in the aggregate, a sufficient number of documents to show in a very general way the upward and downward trend of hardship during the war. In the early months of the war the curve rose steeply, but it went down in the first half of 1940 when many of the civilian services were being re-established. By the end of the year another crisis had
developed, and during the remainder of the war the flow of complaints never completely ceased. During 1944, when severe restrictions were imposed upon civilian hospital admissions to provide for the wounded from Europe, there was another peak.
These letters, some of them pitiable in the humility of their appeals, showed the kind of hardship which many civilians experienced. There were complaints about delayed operations and inadequate treatment as a result of a transfer to a different hospital. There were the elderly people suffering from arthritis or rheumatism who were labelled 'chronics' and refused admission by voluntary hospitals. There were the sick of limited means who were forced to go to nursing homes and found themselves unable to meet the bills. Even during the years 1942 and 1943, when some of th earlier restrictions on admissions had been removed and when the demand for casualty beds was very low, complaints about the failure of hospitals to admit patients in need of urgent operations continued to arrive. Yet many of these hospitals had vacant casualty beds which might have been used.8
With the exception of a limited inquiry in 1942, few facts were collected during the war concerning the size and composition of hospital waiting lists. These lists were not, of course, a particular wartime development,9 and perhaps for this reason they were not at first taken very seriously. At a time when queuing had still to be described as 'Britain's national vice', the invisible and unpublicised queues at hospitals were automatically accepted as a normal feature of the hospital world. Later in the war these queues began to be questioned, and they no longer remained so apathetic and unpublicised. Unused casualty beds suggested that hospital accommodation was being withheld, perhaps unnecessarily. The claims of the emergency medical service could serve as an explanation, rightly or wrongly, for every waiting list, but the Ministry could more easily be called to account than hospital boards. The Department was concerned, therefore, to see that waiting lists were kept within manageable limits.
In 1942 the Ministry arrived at the surprising conclusion that 'at most hospitals the lists are small than in peacetime and at many much shorter'.10 Assuming the conclusion to be factually true, it could not possibly mean that an improved balance had been achieved between the demand for hospital accommodation and the supply of it.
This was a time when thousands of hospital beds were kept free for casualties and when further thousands had been temporarily or permanently lost by bombing and the closing of wards because of air raid risk. Moreover, new demands were growing upon the reduced number of available beds. The plight of old people in London and the needs of transferred war workers have already been described.11 As military and industrial mobilisation proceeded and families were broken up and scattered, many people needed hospital care for comparatively simple complaints. Those who lived alone or away from home in hostels or billets could not be nursed by relatives. Great movements of population about the country led,in many localities to acute shortages of hospital accommodations.The evacuation of mothers and children, the growth of wartime industries, and establishment of army camps in rural areas placed an almost unbearable strain upon the resources of some provincial hospitals. Finally there were the sick Servicemen who received a much larger share of hospital care than they would have received as civilians before the war.
These conditions obtained in 1942 and, indeed, throughout most of the war. The additional hospital accommodation created by the emergency medical service did not make up for all the reserved beds, the losses by air attack and new demands of a kind already described. There was, too, as another factor, the trend of sickness among the civilian population. Claims upon hospital accommodation are strongly affected by changes in the general level of sickness, and the deterioration in national health statistics during 1940 and 1941 suggested that demands for hospital care may have risen in consequence.12 Moreover, the particular population group—the elderly and infirm—which makes substantial calls on hospital accommodation had grown in size since 1938.
If, therefore,the Ministry of Health was right in concluding that the hospital waiting lists of 1942 were shorter than those of pre-war years, there must have been some formal change in the composition of the lists. An analysis of the reports on which the 1942 inquiry was based reveals the nature of the change. In Swansea, for instance, a waiting lists of 1,172 was noted; but it was emphasised that the figure 'is not a true indication of the serious position in the area. A large number of patients who should be hospitalised are not even entered on the list …'. For the whole of Wales, the 'facilities for medical cases are generally so inadequate that such cases are not put down for admission'. In Birmingham, the Children's Hospital turned away at least four to five medical cases daily—they were not entered on
waiting lists—but 'recently a new ward was opened and eleven children were admitted on the day the ward was opened who would otherwise have been refused admission'. A study of these reports suggests that waiting lists were generally reserved for 'surgical cases'; 'medical cases' were not even registered and were usually left to be cared for by overworked general practitioners.
The existence of this large, hidden and unsatisfied demand for hospital treatment was not acknowledged in the Ministry of Health's summary of the situation in 1942. The true significance of these waiting lists can only be judged, of course, by recognising all the hidden demands.13 Even so, the figures that did emerge from the 1942 inquiry—an inquiry, incidentally, that was incomplete because it covered only certain hospitals in each region—were formidable enough. Over 43,000 civilians, including some 6,000 women with gynaecological troubles, were waiting for hospital treatment in England and Wales. In the Manchester region the figures for nineteen hospitals were 11,000 and 2,500 respectively.
Women and children made up a large part of the waiting lists. In Birmingham 'the number of gynaecological patients seeking admission to the Queen Elizabeth Hospital is so great that with the present accommodation and medical staff it will take years to work off'. At some voluntary hospitals children with squints had been waiting for two years; children requiring orthopaedic operations for three months; and children needing operations to their eyes for over two months.14
Many of the patients on these lists were recorded as 'cold' surgical cases, a somewhat cynical description of patients who, in the opinion of doctors, were not needing immediate attention. But waiting for hospital treatment is not just a surgical or medical matter. Long delay may mean weeks or months of worry, discomfort and distress for the patient and for his or her family.15
The 1942 inquiry into waiting lists showed up against the nature of the conflicts in the hospital world which had caused so much difficult in London during the winter of 1940–1. The same financial questions hindered the full use of available beds and discouraged a more equal distribution of patients. There was one hospital, for instance, with seventy-five vacant casualty beds and a long waiting list. 'It is only right for me to explain', commented the group officer, 'that in my opinion this hospital does not make sufficient use of its beds'. He concluded that at least a third of the beds should have been used for ordinary patients. This, however, would have converted the beds from a financial asset into a liability, a consideration which, it was thought by the Ministry of Health, applied to other hospitals in the emergency medical service. When the question arose in 1942 of introducing in England a scheme for the reduction of waiting lists (similar to that already adopted in Scotland16), it was believed in the Ministry that it would not work because 'the hospitals are not themselves concerned about the lengths of their lists.' And when hospital officers tried to place more Service patients in municipal hospitals the voluntary hospitals did not welcome such action. It was said that they 'always do their best to get hold of Service cases as there is a financial aspect.'17
The Ministry of Health could not order hospitals to treat more civilians but it could , by various measures and to a limited extent, improve the position of sick civilians needing hospital attention. It could add new groups to the lists of those entitled to the benefits of the emergency medical service, and it could attempt to free more beds by reducing the number reserved for casualties. Another method, and perhaps the most flexible one, was the use of the so-called 'E.M.S. 116 machinery' for the transfer of patients.18 Originally, this had been designed for the specific purpose of removing civilians from beds, needed for casualties by the emergency scheme in London and other danger areas, to hospitals in the country. These patients became a financial responsibility of the scheme, but they had to contribute to the cost according to their means. This procedure was used to a greater extent than the Ministry had at first intended, and the principles on which it was based received in the course of time a wider interpretation.19 By 1942 these transfers were held to apply to 'any kind of case where a patient is deprived of treatment—or has to wait for it—through E.M.S. intervention in his normal hospital or through other war causes'.
This broad definition gave some hospital officers in London and other bombed areas the opportunity of keeping waiting lists within bounds, provided the hospitals and patients agreed to the transfers taking place, and provided that the beds were available. There was, however, always the difficulty that the receiving hospitals might not be of a sufficiently high standard to deal with patients suffering from certain conditions, or that various specialised services, such as gynaecological units, might be inadequate to meet the need.
In May 1942, when the results of the results of the inquiry into waiting lists were to hand, a number of important questions of policy were formulated by the Ministry of Health. Although some of these lists had been described as 'smaller than in peacetime', the Ministry was seriously concerned about the general situation of sick civilians. Should it now agree to the transfer of sick people awaiting hospital care, even if the fact of their waiting was not due to the activities of the emergency scheme or to the war? If so, could the Ministry add to or improve those particular facilities in emergency scheme hospitals which it did not need for the limited wartime purposes of the scheme?20 Or should the Ministry introduce the Scottish 'waiting list scheme' in England and Wales?
In Scotland, a special 'attack on the waiting lists of voluntary hospitals' had been launched in January 1941.21 Hospitals with long waiting lists were invited to refer sick people from their lists to emergency scheme hospitals for a treatment at a charge (to the voluntary hospitals) of 30s. per patient. After a year's work, during which only people whose stay in hospital was expected to be not more than two weeks were included in the scheme, the result was described as 'small and disappointing'. In consequence, the scheme was extended in January 1942 to all those on waiting lists except the chronic sick. The contribution remained at 30s. regardless of the length of stay of the patient in hospital. As a result of this extension, over 16,000 patients were treated under the scheme in two-and-a-half years, a considerable proportion of them after a waiting period at voluntary hospitals of over three months.22 By June 1945 the number had risen to 32,826,23 and it was then no longer possible to doubt that this scheme to use surplus casualty beds for the benefit of sick civilians had been a decided success.
In England and Wales, this Scottish venture found few supporters. When the Ministry of Health considered it in 1942 the scheme had been in force for only a year or so and it 'did not appear to have succeeded'. It was thought that there would be little response among voluntary hospitals to the idea of paying 30s. for each person removed from their waiting lists. Moreover, the direct administration of emergency hospitals by the Department of Health, which unquestionably helped the working of the scheme in Scotland, had no parallel in England and Wales. From the point of view of the voluntary hospitals, the transfer of patients from waiting lists under the existing emergency scheme machinery, which involved them in non financial obligations, was obviously preferable. The British Hospitals Association in England and Wales, while deprecating 'any departure from existing practice or policy in the matter of each voluntary hospital endeavouring to meet the demands made by the public upon its services', approved of such transfers, but it was opposed to the 'curious arrangement' in Scotland,
It was in these circumstances that the Ministry decided in July 1942, to use the existing procedure for transferring patients with 'more elasticity'.24 Where the transfer was from a voluntary to a municipal hospital in the same area the Ministry accepted no financial responsibility, but in other instances—and the new rules applied to all general hospitals with waiting lists25—the 'E.M.S.116 machinery' was used and the additional costs were borne by the Ministry. If the specialist services in the receiving hospital were found to be inadequate for the needs of the transferred patients, the regional or sector hospital officers were empowered to arrange for the establishment of new specialist units by established of new specialist units by moving staff from other hospitals, or by persuading other hospitals to share their staff. The new rules for the reduction of waiting lists were not circulated to the hospitals themselves; it was left to the responsible E.M.S. officer in each sector or region to apply them whenever necessary.
Despite all the practical and psychological handicaps, the Ministry of Health succeeded in effecting some reduction in the waiting period for some sick civilians. How well it succeeded cannot be estimated; nothing short of a national survey covering the records of each hospital would suffice to measure, however roughly, the degree of achievement. Difficulties of measurement cannot, however, obscure the fact
that both the Department of Health for Scotland and the Ministry of Health undertook the first real attack upon voluntary hospital waiting lists ever undertaken.
The deprivations of hospital service for physically sick civilians were paralleled in the mental hospitals and mental deficiency institutions. More than 25,000 of their beds in England and Wales, including some complete hospitals, were given up and handed over to the emergency medical service and to the Service authorities.26 In addition, other institutions were wholly or partly reserved for mental patients from the Armed Forces.27 Bomb damage, and the necessity of relinquishing some institutions situated on the coast, still further reduced the accommodation available for mental patients from the civilian population.
It was not, therefore, surprising that overcrowding in mental hospitals, which amounted to 2·3 percent in 1938, rose to 14·4 percent in 193, and to a peak of sixteen percent in 1940.28 In other words, the mental hospitals in England and Wales were compelled to squeeze 116 patients into the space originally occupied by a hundred. In the mental deficiency institutions a surplus of 337 beds in 1938 was converted, by the needs of war, into a deficit of 6,000 beds by 1943—an overcrowding rate of fourteen percent. Towards the end of the war there was a fall in both these rates, but they were still as high as 11·5 and 12·9 percent respectively in 1945.
Shortages of space and staff in the mental hospitals, bad ventilation during 'black-out' hours and other factors 'created conditions in which the health of the patients was bound to be adversely affected'.29 The consequences were reflected in a higher death rate, particularly from tuberculosis, and an increased number of patients suffering from this disease.30 'But the effects of overcrowding are not only physical. When beds are too near to each other and contact between patients during the day is too close, the patient seems to become part of a mass rather than an individual member of a group; physical and mental discomfort is increased and nursing and medical treatment loses much of its value'.31
Among both mental hospitals and mental deficiency institutions there were fewer admissions and more discharges during the war than before. So far as the mental hospitals were concerned, the causes were
very complex; shortage of accommodation was only one among many. There can be little doubt, however, about the reason for these changes in the work of the mental deficiency institutions. The fall in admissions was to 'shortage of beds, as every local authority still reports a long waiting list of patients in urgent need of institutional care', and the rise in discharges was explained by 'emergency medical service requirements' and 'pressure on institutional accommodation'.32 In other words, many mental defectives who should have been in institutions were either not admitted or were discharged too soon. 'Unlike psychotics, defectives of ten show no dramatic need for institutional care. They can remain at home without apparent failure, but in many cases only at the expense of much suffering to themselves, to their families and to the community. Social and domestic damage is especially apparent in the case of court cases and of low-grade defectives, many of whom have now to be left in the community without the needed institutional training and control.'.33 This was not only a description of what happened during the war; it was also an explanation of the cause of certain social ills which the community inherited—and which continued to fester—after the war.
Perhaps the most depressing entires in this wartime record of shortage and sacrifice concern the fate of children in need of hospital and convalescent care. The effect of the war on the special schools for physically handicapped children, for instance, was 'profoundly disturbing', and the accommodation in residential schools for mentally defective children was said, in 1943, to be 'quite inadequate'.34 Many of the hospital schools, providing treatment for children and special educational facilities, were taken over partly or wholly by the emergency medical service and used for other purposes. Some of the convalescent schools for crippled children suffered in the same way. In addition, a considerable number of these residential schools catering for various classes of handicapped and sick children had to be closed because of their situation on the south and south-east coasts.
These disturbances and losses were partly responsible for the fact that, throughout the war, there was an acute shortage of convalescence facilities for children. Some children, who were not at first seriously ill, later developed chronic complaints because hospital treatment was not followed by a period of convalescent care. They then drifted back into hospital and occupied beds which were needed by other patients. At the same time, convalescent beds were standing empty. Among the auxiliary hospitals earmarked for civilian patients, only two or three were ready to admit child convalescents who, as the
Ministry of Health remarked in October 1942, 'have not been very welcome in the auxiliaries'.
By the end of 1942 it was apparent that the waiting lists for convalescence at children's hospitals were growing to serious lengths. The Charity Organisation Society35 and the Invalid Children's Aid Association were inundated with applications, and they appealed to the the Ministry for help in the provision of beds in auxiliary hospitals and offered to pay the cost.36 The Ministry again approached the British Red Cross War Organisation, and after months of negotiation an agreement was reached.
It had not been easy to find auxiliary hospitals which were both suitable for children and ready to admit them. In many regions the search proved fruitless, but ultimately eight hospitals with a total of 374 beds were set aside for child convalescents over five years of age. No general circular was issued to notify other hospitals and organisations of this new provision—the number of applications might have been too great—and it was left to hospital officers to make the best use of the available beds. It transpired, however, that the scheme was even more limited than it had appeared when it was launched in March 1943. Only a few weeks later the owner of the largest auxiliary hospital in the scheme withdrew his agreement allowing the admission of children,37 and in the following year most of the children in the other hospitals had to make way for the reception of Service patients from the Continent.
It is clear that children, far from occupying a privileged position in the wartime hospitals, had to make their contribution to the social costs of the emergency medical service. At the other end of the age scale, elderly and old people were compelled to make an even larger contribution to the success of the service. Because many of them—designated the 'chronic sick'—suffered from diseases needing prolonged medical and nursing care, their demands on the hospitals were great.38 These demands, already substantial before 1939, increased
during the war, largely as a result of all the disturbances to family life, the break-up in cities of settled groups of neighbours and friends, and the destruction of homes by bombing. The claims of this group on hospital accommodation throughout the country were, in fact, so substantial that there was bound to be conflict between their needs and the wartime needs of air raid casualties and members of the Armed Forces. This conflict could be resolved only in one way; the aged sick and the infirm had to suffer.
The sacrifices imposed on this group in the interests of Britain's war effort took two forms: more of them excluded from hospital care,39 and a proportion of those who were admitted had to accept inferior standards. These experiences were illustrated in Chapter XXII, which discussed the difficulties of sick civilians in London during the winter of 1940–1, and described the scheme for removing old and infirm people from shelters to hospitals in the country.40 As a result of this scheme and other arrangements for the transfer of patients from one hospital to another, some of these aged sick found themselves in institutions which for long they had dreaded. While younger patients were usually transferred from one general hospital to another, the elderly and chronic sick were sometimes shifted from place to place until they ended up in institutions of the workhouse type.41
The shock of the country women who billeted children from the slums was not greater than that of patients, accustomed to London's hospitals, who were transferred to some of the bleak public assistance institutions in the country. Husbands and wives and friends were
separated,42 pension books impounded and records lost.43 These indignities of the poor law were visited only on some, but there were enough to create many protests to local authorities and social workers. Eventually, action by the Ministry of Health remedied the worst of these complaints.
It was not long, however, before they were joined by other protests from people who, after being used to the amenities of middle-class life, found themselves in public assistance institutions and public hospitals of a similar character.44 This was one result of the shortage of domestic help for the old and infirm allied, in many instances, to the increased cost of prolonged care in privately-run institutions and nursing homes.
The arrival of some middle-class patients in public assistance institutions, painful as it must have been for the patients themselves, led to a good deal of publicity and some vigorous complaints. Conditions which previously had been known only to the sick and aged poor were, as a result, more widely discussed by doctors, welfare workers and the general public. These were but some of the streams of awakening concern to the social problems of old age which, in the immediate post-war years, broadened into a strong current of public interests, research and medical investigation.45 If the conception of a collective conscience has any reality, then it may be said that the British people began to show, in the late nineteen-forties, many symptoms of uneasiness about their treatment of old people before and during the Second World War.
Towards a National Hospital Service
This final chapter on Britain's wartime hospitals ends, inevitably, on a sombre note. Much of it has had to be devoted to an account of work not done or done indifferently. It is, in great measure, the story of people, from the very young to the very old, who were deprived of hospital care because there was a war and because national survival was more important than the relief of individual needs. This record—or social history—of hospital work would not have been complete if the debit entries had been left out. But seen as a whole and in historical perspective, even the apparently negative and depressing passages acquire meaning and purpose. The Government's policy on the development of the emergency medical service during the war was increasingly influenced by the continuing story of civilian difficulties and deprivations. Again and again, the unyielding logic of these facts forced upon the Government decisions which, at an earlier date, it had been disinclined to consider.
In 1939—in contrast to the position reached by 1942—the attitude of both the Government and the medical profession to the problems of hospital needs of all groups in the community had been very different. The question of organising hospital provision for war victims was approached as a separate and self-contained issue. It was agreed that the existing pattern of hospital organisation should be preserved for the civilian population, but for those patients, regarded by the Government as its own responsibility in wartime, a nationally planned and financed service, based on regional groups of hospitals, was accepted as the only satisfactory solution.
With the formation of the emergency hospital scheme, new areas of tension were added to those already in existence. In theory, at least, there were now two hospital services in England and Wales superimposed on two hospital systems; one service for special wartime purposes and another for the ordinary sick. One was nationally directed and financed; the other was not. The same doctors and nurses worked sometimes in one, and sometimes in the other. The dividing line ran right through the individual hospital. Strong and repeated efforts were made to keep it in sight, but often it was blurred and occasionally it was invisible.
The Health Departments soon found that they could not limit their interests and activities to the emergency sector of the hospital services as they had originally intended. Government responsibility was expanding in nearly every branch of social provision, and hospital work
could not continue to be unaffected by the general trend of social development. In total war the troubles of individuals often multiplied until they became matters of national concern, while the demands of humanity pointed, just as often, in the same direction. Inevitably, the Health Departments found themselves assuming, almost unconsciously, the role of principal advocate for the welfare of sick people. As this role grew in importance, and as the Departments continued to discharge their duties towards war victims, new and hitherto unattended responsibilities crowded in; the standards and conditions of work among nurses became, for the first time, matters of direct concern to the Government, so, too, did the kind of food that patients received in hospital, their fitness for work when they were discharged and many other aspects of hospital care.
The assumption by the central authorities of these new responsibilities was at the same time stimulated by the progress and achievements of the emergency hospital scheme. Developments in one branch of the hospital services could not fail to influence those in another. Both war victims and sick civilians needed hospital attention and it was in the public interest that they should get it. But the hospital resources of the country were not large enough for this double task, and they were not, moreover, always used to the best advantage. All through the war painful issues of priority arose which could not be settled at the centre. There was no authority in a position to tackle the problem of hospital needs as a whole. The means and the powers of the Health Departments bore no relation to their greatly enlarged field of responsibility. As a result, the price paid by the civilian sick for the achievements of the emergency hospital scheme was larger than it would otherwise have been.
The price was increased, too, by the conditions of strain and shortage in which the hospitals had to do their work. The Armed Forces inevitably had prior claims on doctors, nurses and other hospital staffs, and the war industries absorbed many of the domestic workers. The nursing problem, already present before the war, became more acute as demands increased, thus forcing the Government to concern itself with questions of recruiting, distributing and keeping nurses in hospitals.46 As regards the supply of doctors, the position was that in the later years of the war most of those who still staffed the civilian hospitals (apart from the newly qualified and inexperienced) were the elderly and the unfit.47 Many of the doctors—and nurses, too—had to carry a heavy load of responsibility when, in more normal
times and by virtue of their age, their burdens would have been eased. The price for the success of the emergency medical service was, therefore, partly paid by the hospital staff themselves in terms of long hours of work and crowded hospitals under the strains of war and bombing. In all other respects the social costs fell upon the civilian patients, men, women and children, who stood at the end of the queue for hospital beds. Part of this cost was carried over into the post-war years.48
The emergency medical service should not, however, be judged solely on its achievements in action and the costs it entailed. It left behind a heritage of advances in hospital care, and a fund of knowledge and experience in organisation and administration. It demonstrated, in its limited field, what a hospital service could be, and it gave many institutions of varying character and type their first real opportunity to work together for a common purpose. This was not the result of deliberate acts of policy. History was often made by seemingly insignificant and unconnected decisions imposed by immediate necessities and carried out despite formidable psychological and practical handicaps. The demands of war were inescapable, but once accepted, they produced ideas as relevant to the needs of peace as of war.
It was only two years after the outbreak of war—and just when a second winter of air bombardment was expected—that the Minister of Health and the Secretary of State for Scotland made their statement about the future of Britain's health services. 'It is the objective of the Government', they said, 'as soon as may be after the war, to ensure that by means of a comprehensive hospital service appropriate treatment shall be readily available to every person in need of it'.49 At
that time no fundamental changes in the ownership and finance of hospitals were contemplated, but it was announced that hospital surveys would be started immediately 'to provide the information needed as a basis for future plans'. By 1946, when the last results of the surveys had been published, more was known about Britain's hospital resources and needs than had ever been known before. This was the first step on the road towards reconstruction.
Contents * Previous Chapter (XXIII) * Next Chapter (XXV)
1 Summary Report of the Ministry of Health for 1941–2 (p. 25).
2 Section 34 of the Defence Regulations, 1939, empowered the Minister of Health, and any person authorised by him, to give directions with regard to the management and use of hospitals in order to secure proper hospital treatment for persons 'who may be suffering from any injury, disease or incapacity in consequence of war operations or who may leave their homes in consequence of in apprehension of attack by an enemy'.
3 It took from December 1940 until January 1942 to carry out the cuts in bed reservations proposed by the Ministry when it was found that fewer emergency beds were required than had been estimated. See Chapter XXII, p. 453.
4 Ministry of Health circular E.M.S.I.258, 5th December 1940.
5 This was not so true in the early stages of the war (September 1939 to about January 1940) when the Ministry was not disposed to be sympathetic or to take much action about complaints received.
6 To the numerous letters received at the Ministry of Health there was a more of less standard reply that 'the Minister has made it clear to all hospitals and hospital authorities that patients in urgent need of institutional treatment must be admitted to hospital, notwithstanding the international situation, and, if your medical adviser is of the opinion that it is urgently necessary for you to be admitted to hospital, he should be able to arrange that for you'. In the most pathetic instances, the Ministry took the matter up with hospital officers.
7 One instance was reported in the press after a public inquest. A window-cleaner in Yarmouth had a fall, sustained injuries and was taken to a local hospital. He was treated and sent home. Within a few hours he was dead. The only empty beds at the hospital were reserved for casualties. At the inquest the coroner gave his opinion that perhaps the man should have been kept in hospital (Lancet, 1940, i, 473).
8 For example, a voluntary hospital in Berkshire with fifty vacant E.M.S. beds refused to admit a badly injured child, and was unable to give any adequate reason for its action. A departmental minute described the affair as 'criminal'. Many other instances of hospitals refusing to admit civilians were recoded in departmental files.
9 The pre-war position was described in Chapter V, p. 73.
10 Minute by a high official of the emergency medical service on 18th April 1942, summarising the information sent in by hospital officers in reply to a circular of February 1942 inquiring about waiting lists.
11 Chapter XXII, pp. 450–2.
12 These statistics are examined in Chapter XXV, pp. 517–31.
13 'In addition to apparent shortage, there can be little doubt of the existence of a considerable hidden shortage which is brought to light whenever a good new service is established. For example, a local authority appoints an obstetric and gynaecological consultant and gives him beds in municipal hospital; very soon the number of beds provided has to be increased and everyone wonders how it was possible to get along before the new department was created … The general conclusion that there is a considerable hidden need and total shortage of hospital beds seems to be inescapable.' (Hospital Survey of the North-Western Area reporting on the 1938 position, Ministry of Health, 1945.)
14 Waiting lists were included in the survey only if hospital officers considered to them to be disturbingly high. Consequently, no comparison can be made with the total of hospital waiting lists either before the war (Chapter V, p. 73) or in 1946 (p. 504 below).
15 'Long waiting lists entail more hardship than is perhaps generally realised, for although it is usual to give priority to those patients who are suffering from malignant disease or other urgent illness, there are many conditions which, though not dangerous to life, give rise to disability or debility which seriously interferes with the patient's work and livelihood. Further, the psychological effect on some patients of waiting for weeks and perhaps months before they are admitted to hospital cannot be overlooked.' (Hospital Survey of the North-Eastern Area reporting on 1938 position, Ministry of Health, 1946.)
16 See below p. 495.
17 Letter from regional hospital officer to the Ministry of Health, 16th March 1942.
18 E.M.S.116 was the form on which the names of the patients to be transferred were submitted to officers of the emergency medical service. The form was originally issued with Ministry of Health circular 1938A on 29th December 1939.
19 .See Chapter XXII, pp. 446–7
20 There were long waiting lists, for instance, for gynaecological and ear, nose and throat operations. The emergency medical service, primarily conceived to deal with the casualties of war, was not generally equipped for such work.
21 Health and Industrial Efficiency, published by the Department of Health for Scotland, July 1943 (p. 8).
22 Health and Industrial Efficiency, published by the Department of Health for Scotland, July 1943 (p. 8).
23 Summary Report of the Department of Health for Scotland for 1945, Cmd. 6661 (p. 15).
24 Ministry of Health circular E.M.S.370, 14th July 1942. The gradual extension in the use of these arrangements was reflected in the figures of patients whose transfers were recorded on E.M.S.116. From a little under 59,000 in 1940, the number rose steadily to 1943 when 126,000 patients were transferred; in the following year it fell to 73,000, and in 1945 to 60,000. The total number of patients transferred during the years 1940 to 1945 was over half a million (figures collected for the Medical History of the War under circular D.G.I 170, 12th August 1942).
25 Hospitals for infectious diseases and tuberculosis, mental hospitals and institutions, and mothers confined in hospitals were excluded (Ministry of Health circular E.M.S.370, 14th July 1942).
26 Annual Report of the Board of Control for 1945.
27 The emergency medical service was not responsible for mental patients from the Armed Forces. The Services ran their own mental hospitals, where patients could be kept under military discipline without the need for certification and all that it involved (Annual Report of the Board of Control for 1945, p. 8).
28 In 1938 there was a deficiency of 2,993 beds and in 1940 the deficiency was 18,227 beds (Annual Report of the Board of Control for 1945).
29 Annual Report of the Board of Control for 1945 (p. 1).
30 Ibid. (p. 18).
31 Ibid. (p. 13).
32 Annual Report of the Board of Control for 1945 (pp. 18–20).
33 Annual Report of the Board of Control for 1945 (p. 19).
34 Report of the Chief Medical Officer of the Ministry of Education, 1939–45 (pp. 82–90).
35 Later known as the Family Welfare Association.
36 The Charity Organisation Society, in writing to the Minister of Health in October 1942, said that 'the problem of providing convalescent treatment for children is rapidly becoming a nightmare', and reported that one society—the Invalid Children's Aid Association—already had a waiting list of 500 children. At about the same time the Gt. Ormond Street Hospital (London) for Children raised similar questions. Convalescent facilities were needed for the children it was treating so as to enable the hospital to free some of its beds and reduce its waiting lists. In November 1942 this list consisted of 43 medical cases, 511 surgical cases, and 1,321 tonsils and adenoids cases.
37 This was a mansion in Worcestershire, converted into an auxiliary hospital, and providing 100 beds.
38 The number of 'chronic sick' and 'aged infirm' in hospitals and public assistance institutions in England and Wales was estimated at 78,000 in 1946 (Report of the Working Party on the Recruitment and Training of Nurses, July 1947). But this figure does now show the true size of the problem. There is no clear line of division between chronic and curable, or long-stay and short-stay hospital patients, least of all in a service where the term 'chronic' has generally been used with insufficient discrimination. No one knows, for instance, how many 'chronic sick; might fully or partly recover if their medical and nursing care were adequate. On the other hand, no one knows how many sick and infirm people are not in hospitals and institutions because there is no room for them, or because they refuse to enter. The total of 78,000 patients mentioned above excludes people suffering from tuberculosis and accommodated in sanatoria. The wartime difficulties of these people, and the general problems which faced the tuberculosis services, will be considered in a second volume in this series of histories.
39 A Memorandum on the Care of Chronic Sick, prepared by the Institute of Hospital Almoners in May 1946, summarised the results of a survey and concluded that there was a 'great shortage of accommodation for patients suffering from advanced malignant disease for whom continuous nursing is required'. An investigation by the public assistance officer for Kent showed that by 1946 the hospital organisation in the county for chronic sick patients had 'completely broken down'. There was a waiting lists of 650 places, a large proportion of whom were desperately ill and urgently needing nursing care, while many old people were dying in their homes unattended (Public Assistance Journal and Health and Hospital Review, 8th February 1946, p. 106).
40 See above, pp. 450–2.
41 The Ministry of Health's Hospital Survey for the Yorkshire area (1945) summed up the problem of the chronic sick in institutions of this kind: '… it is true to say that in general the care of the chronic sick requires complete and revolutionary change if these people are to be adequately cared for and looked after in a reasonably humanitarian and social sense'.
42 The following example, taken from the files of the Islington Charity Organisation Society, may not be typical but it illustrates what happened to some old people. Mr. and Mrs. M. were bombed out of their home, and when Mr. M. was discharged from hospital he could not find out where his wife had been sent. Inquiries began in October 1940 and went on for a long time. Finally, her death was presumed in 1943. Later, the Poplar Citizens' Advice Bureau took up the search again, and Mrs. M. was found to have been transferred to Cannock Public Assistance Institution in October 1940. She had sustained a shock as a result of the bombing and could not speak very clearly. She did not, of course, know where her husband was. She died in this institution in May 1941.
43 Many of the patients moved from hospital to hospital were mentally or physically unable to notify their relatives or friends themselves, and because records were not kept or were mislaid the whereabouts of some of these old people could not be traced for weeks or even months. Thus, twenty-one old people transferred from Bermondsey in October 1940 to institutions in the country were still 'missing' in May 1941.
44 For instance, a retired colonel, suffering from paralysis agitans, had to be admitted to a public assistance institution because his wife had no domestic help and could not get anyone to help her look after her husband. A 'middle-class woman' of forth admitted to a London teaching hospital in 1939 was sent, on the outbreak of war, to a teaching hospital in Oxford. From there she was moved on to Chipping Norton and placed, according to the Ministry's informant, in 'this very bleak poor law institution, in a most poverty-stricken small bedroom, with two old ladies aged seventy-six and eighty-four'. Other example of people with means being taken into public assistance institutions because their relatives could not look after them were cited in Public Assistance Journal and Health and Hospital Review, 15th March 1946 (p. 213).
45 See, for example, Old People: The Report of a Survey Committee on the Problems of Ageing and the Care of Old People (1947), and The Social Medicine of Old Age Report of an inquiry in Wolverhampton, Sheldon, J. H. (1948).
46 In the spring of 1945 hospitals in England and Wales reported a need for over 16,000 additional nurses, and in Scotland the estimate was nearly 2,000. An account of the problems of nursing and midwifery during the war, with particular reference to the needs of hospitals, sanatoria and maternity homes, will be included in a second volume in this series of histories.
47 Some further reference is made in Chapter XXV (pp. 530–1) to the question of the number of doctors serving the civilian population during the war.
48 A survey of waiting lists among voluntary hospitals in the Greater London area, undertaken in June 1946 by the voluntary hospitals' emergency bed service, showed a total of some 33,000 people waiting admission. The secretary of this service, reporting to the Director-General of the E.M.S., wrote: 'The worst delays occur in female, surgical gynaecological, orthopaedic and ear, nose and throat cases, in which categories it appears that it is fairly common for a patient to wait for a year or more. In some hospitals the ratio of patients awaiting admission is out of all proportion to the beds available'. If the relationship between these waiting lists and the total population of Greater London were broadly applicable to the whole of England and Wales, then it would seem that roughly 200,000 people in the country were awaiting hospital treatment a year after the end of the war. This is about double the estimate made on a similar basis for 1938–9 (see Chapter V, p. 73). A strict comparison between the two estimate it not, of course, possible, one reason being that not all voluntary hospitals in the Greater London area participated in the 1946 inquiry. To this figure of 200,000 for 1946 some addition should be made for waiting lists at public hospitals (there were, apparently, very few people on these waiting lists in 1939—see Hospital Survey reports). An inquiry in November 1946 by the Medical Officer for Kent showed that there were 822 chronic sick people awaiting admission to public hospitals in the county. If the situation in Kent at that time was more or less true of the whole of the country, then a further 25,000 people (making 225,000 in all) were in the queue for hospital beds.
49 H. of C. Deb., 9th October 1941, Vol. 374, Col. 1116.