PREPARATIONS: THE EMERGENCY MEDICAL SERVICE
The direct and indirect consequences of war have, in the past, profoundly influenced the development of the nation's medical services. War in general, not just one particular medical services. War in general, not just in particular war, has provided clinical and surgical material for experimentation on a grand scale, and has imbued society upon each outbreak with a fresh interest in health.
Because war means the organisation of killing and wounding it must also mean the organisation of services to repair and heal. In the early campaigns of the Roman Empire sick soldiers were sent home for treatment. But as the frontiers spread wider this became impossible, and military hospitals were founded at strategic points.1 The Crimean War lead, through the work of Florence Nightingale, to the creation of nursing profession and to improvements in hospital administration;2 recruitment for the Boer War revealed defects which directed attention to the physique and health of children and stimulated the provision of school meals and a school medical service, while the First World War gave birth to the Ministry of Health, spurred on the movement for the care of mothers and young children, and led to a scheme for the diagnosis and treatment of venereal disease. These were not new ideas; the momentum of war spread and quickened a trend towards social altruism, and crystallised within the nation demands for social justice.
The accumulated lessons, both good and bad, which emerged from the experience of war to shape in peacetime the structure of medical care, had been generally acquired after war had broken out and in the process of fighting it. But this is by no means true of the Second World War. The frame and pattern of the hospital services at the end of the war was due as much—if not more—to the kind of war that was expected as to the kind of war that happened.
This is an important historical fact. The estimates of the Air Staff, the translation of these into figures of casualties and hospital beds, and the prevailing mood of fear and alarm about the character of a future war had largely determined, by the end of 1938, the way in
which the medical services of the country were to be organised eventually. The outline of Britain's first attempt to create a national hospital service was clearly pictured before the war began.The Medical History of the War will tell, at greater length and in much more detail, the story of this service; the administrative and technical questions that arose, and the clinical problems that were encountered. It is only intended to give in this book a general medical care, including the diagnosis and treatment of disease, belong to the clinical volumes of the Medical History. There, too, will be found full accounts of the wartime casualty services, the emergency laboratory service, the blood transfusion service, the organisation and deployment of medical, nursing and technical staff, the development of convalescent homes and special centres for certain types of injury and disease, and the relationship of all this work to the care and treatment of the sick and wounded of the Armed Forces. The reader who notices in the following pages that a particular problem has not been discussed or has been inadequately investigated should therefore turn to the Medical History.3
The Central Problems of Planning
The present chapter is concerned with the central problems of planning which faced the Government up to the outbreak of war. It deals, first, with the preparatory work which led, in June 1938, to the Ministry of Health being charged with organising a national service for air raid casualties and, secondly, with the form of the service itself. From this point the narrative proceeds to ask the question: how many hospital beds should the Government provide? This immediately raises a number of issues: what was the existing hospital service like? how much accommodation was there? where was it, and could it be used:? A study of the resources available before the war throw light on the problems which the Government had to meet, and helps to explain the methods adopted to expand the quantity of accommodation and to raise the quality of hospital service. The chapter ends by describing in broad outline the organisation of the emergency hospital scheme on the outbreak of war.
The early period—up to the middle of 1938—in the history of preparations for an emergency hospital scheme was characterised by the now familiar processes of analysis and discussion which went on
in the planning of evacuation and other measures. The shifts in emphasis from this to that point of view, the changes in departmental responsibilities, the transition from leisurely speculation to urgent administrative activity and, finally, the hurried execution of policy are just as much as part of the history of the hospital scheme as they ware of other wartime services.
The first important event in the story of preparations was the establishment of the Air Raid Precautions Department in April 1935. Before this, it had been thought that the Health Departments were the appropriate agencies to organise hospital and other casualty services. The Ministry of Health had, in fact, prepared—as early as 1926—a report for the Committee of Imperial Defence on a casualty scheme for the London area. It was concluded that 36,000 beds would be required at the outset on the basis of current Air Ministry estimates. It was proposed that there should be casualty clearing hospitals in the target areas and base hospitals in the country. This conception of two types of hospitals with different functions, which owed its inspiration to military experience during the First World War, dominated the approach to the problem for several years, and introduced a number of administrative and financial difficulties. It was some time before these were overcome.
In April 1935 the responsibility for planning a casualty service passed to the newly-created Air Raid Precautions Department, and in the following July the first circular was issued to local authorities outlining in some detail the kind of services that would be needed. It was suggested that preparatory work should begin on the planning of first aid, hospital and ambulance schemes.4 The principles of decentralised administration and divided responsibility were thus established by the decision to graft these services onto the existing system of local government.
For three years, from July 1935 to June 1938, the conception of casualty clearing and base hospitals administered by different authorities remained part of official policy. The first were intended to form part of an air raid precautions medical organisation, they were to be run by local authorities under the direction of the Air Raid Precautions Department, and part of the cost was to fall on local revenues.5 The responsibility for organising and financing the second type—base hospitals in the safer areas—was not finally settled by Ministers until December 1937. The Ministry of Health then became
the department responsible for base hospitals, the cost falling entirely upon the Exchequer.6
While the Air Raid Precaution Department was strongly in favour of two types of hospitals, it soon became apparent that the division of functions was leading to departmental competition, for the air raid precautions organisation wanted all existing and equipped beds for the reception of casualties, thus leaving the Ministry of Health to provide base hospitals in tents and improvised premises. The idea of a unified national hospital service, providing for soldiers and civilians and the sick as well as the injured with the object of utilising to the full all hospital beds and staff, had not therefore been accepted by the beginning of 1938. There were many reasons for this. The creation of a separate department which, whatever the original intentions of Ministers may have been, came to be regarded as the central authority for all aspects of the problem of protecting the civilian population and maintaining the nation's vital activities, led to an unfortunate divorce of the peacetime responsibilities of certain departments from the functions they would have to assume in the event of war. One department for civil defence planning meant, during the period from 1935 to 1938, two departments interested in hospitals. Confusion and delay in the drafting of schemes and in the formulation of policy was, therefore, inevitable, as the preceding chapter had already pointed out in another connection.7
A second reason was the under-staffing of the Air Raid Precautions Department and its inexperience in hospital matters. At no time did it have more than three medical officers on its establishments to deal with the planning of hospital, first aid and ambulance schemes.
A third obstacle to unity of policy and management was the problem of treating sick and injured soldiers. Awkward questions of discipline and administration were involved, and the War Office had grounds for believing that Service patients would not be returned to duty from civilian hospitals as quickly as if they were in hospitals under military control.8
A fourth and stronger obstacle was the doctrine of local responsibility. It led to the splitting of the cost of hospital care for air raid casualties and thus strengthened the conception of two types of hospitals; one financed by the Treasury, the other partly by the Treasury and partly by local authorities. This division in terms of finance was made before the functions of a wartime hospital scheme had been clarified. For long, the Treasury clung tenaciously to the principle that ratepayers should bear at least a part of the cost of the medical care of their neighbours injured by air attack.9 Agreement with the Treasury on central responsibility was not obtained until local authorities had been persuaded to meet certain initial expenditure on the ground that they were being relieved of their duty under the Air Raid Precautions Act to provide casualty clearing hospitals. The terms of the quid pro quo were not settled with local authorities until December 1938. Finally, the complicated pattern of the hospital systems, and the multiplicity of local authorities and voluntary agencies concerned, did not make for clarity of thought and did not encourage acceptance of the principle of unified control.
Eventually, some of these barriers to unity were lowered. But this was not until the estimates of civilian casualties had reached an alarming figure, and war seemed imminent. Only then was logic sufficiently impressive to overcome, at least for a time, the resistance of many interests.
On 1st June a big advance was made. The Government decided to abolish 'the unworkable'10 between base and casualty hospitals. The Health Departments were henceforward to be responsible for the organisation of a national hospital service for civilian victims of air attack. The task of providing an immense number of additional beds, staffed and equipped to receive the expected civilian casualties, made it impossible any longer to regard the problem as a local responsibility. It was a national problem; all medical resources would have to be pooled, and every available bed might have to be called into use.
The question of divided responsibility also affected the organisation of the casualty services—first aid posts and parties and ambulances. After the duty of directing the hospital scheme had been transferred to the Ministry of Health in June 1938, it was realised that injured civilians who received treatment at hospitals would come under the jurisdiction of one department, while those who found their way to
first aid posts would be the responsibility of another—the Air Raid Precautions Department. Where should the line now be drawn between on the one hand, the casualty services and, on the other, the hospital scheme? For many months the two departments disagreed; one stressing the need for a unified civil defence and casualty service, the other emphasising the importance of a single department being responsible for the continuous treatment of all injured civilians. In addition, different views were held about the functions of first aid posts and parties. The Ministry of Health believed, unlike the Home Office, that a doctor should be in attendance at the post, and if placed much more emphasis on first aid treatment as a protection against the danger of hospitals being swamped with tens of thousands of slightly injured people.
The Munich crisis in September 1938 helped to bring these problems into focus, and in December it was decided to transfer the responsibility for first aid posts, points, mobile units and the ambulance service from the Home Office to the Ministry of Health.11 The provision of such services remained the task of local authorities.12 It became the duty of the Ministry of Health—instead of the Home Office—to direct and approve the arrangements they made. This change brought about a closer relationship between the hospital and first aid services.
Some measure of dual control remained, however, as the Home Office continued to be responsible for first aid parties, the recruitment of personnel and their preliminary training in first aid.13 A number of local authorities, whose task it was to organise these services with the approval of the two departments, found these arrangements irksome. A year later, in December 1939, a further transfer of duties to the Ministry of Health took place, when responsibility for the supervision of collective training and exercises for first aid was passed to the Director-General of the emergency medical service. Thus, in piecemeal fashion, certain responsibilities which the Air Raid Precautions Department had held for over three years were transferred to the Ministry of Health.
By the outbreak of war, the relationship between the hospital and the first aid post, and between the first aid parties and the civil defence organisation, had become clearer, while the principles on which the emergency hospital scheme was to rest had been settled. Treatment at hospital, either in-patient or out-patient, was to be the basis for dealing with air raid casualties. The scheme was to be
controlled and directed by the Ministry of Health.14 Unlike, therefore, the civil defence and first aid services, administration was not delegated to local authorities. There were good reasons for this difference in policy. The voluntary hospitals would not have agreed, while the magnitude of the expected number of civilian casualties, uncertainty as to where they would occur, the shortage of beds and medical and nursing staffs, and the maldistribution of specialists, consultants and technical equipment, made it virtually impossible to delegate control to hundreds of separate local authorities and individual voluntary hospitals.
The general principle underlying the arrangements was that all existing hospital accommodation, and such expansion as could be provided, had to be pooled and coordinated on a regional basis. The great majority of hospitals were therefore expected to treat or give first aid to casualties resulting from air raids in their locality, while those outside the dangerous areas were expected, in addition to carrying on their ordinary work, to receive for further treatment both casualties and other patients transferred from the towns.15 Each hospital authority or governing body continued to be responsible for the maintenance of its service, while the Government assumed power to determine the type of work for which each hospital could bets be used, including the reception and transference of both casualties and ordinary patients.16
This was the plan for dealing with air raid casualties. In drawing it up, and in working out the structure of the organisation, the Ministry of Health was worried because one important question had not been settled: the problem of hospital treatment for sick and wounded servicemen. This chiefly concerned the Army whose needs were expected to be far greater than those of the other two Services. When the problem was considered by the Committee of Imperial Defence in 1937 it was decided that the Army and the Navy should make their own arrangements. Servicemen and women needing hospital treatment should, 'as far as practicable, be admitted to Service hospitals and remain under Service control'17 The Ministry of Health, after it had been given the task or organising a hospital
scheme for civilian casualties, thought that if this arrangement was not modified it would lead to an unseemly and wasteful competition for hospital space, equipment, doctors and nurses.
The Ministry first took action in September 1938 when it put before the Minister for Coordination of Defence the suggestion of a unified hospital service. This was not accepted. The Ministry was left to argue it out with the War Office. During the stress of the Munich crisis an agreement was reached that, for the time being, the War Office would take over only four hospitals in Britain, instead of the twenty-nine previously contemplated. In return for this undertaking, the Ministry of Health and the Department of Health for Scotland agreed to hand over whatever future hospital accommodation was required within forty-eight hours, in addition to taking military casualties into civil hospitals.
Five months later, however, the War Office obtained Treasury approval for twelve new hospitals and began earmarking buildings. The Ministry of Health again raised the question of a combined service. The Cabinet was asked to approve the principle of unified control of all emergency hospital accommodation in the country—both for civilian and Service needs. But the War Office objected because it felt that the Ministry of Health had not appreciated all the Service problems involved. This was probably true. A little later, an understanding was reached between the two departments, and the War Office agreed as a temporary measure not to mobilise fully the hospitals it required on the outbreak of a war. By September 1939 it had not been possible for the War Office to develop the additional hospital accommodation it required, and it thereupon asked the Health departments to allot for Service needs a certain number of hospital beds.
From this point there developed, during 1940–1, a state of affairs which approximated fairly closely to the Ministry's proposals for a unified service. The emergency hospital scheme ultimately provided a large proportion of the hospital accommodation required in Britain for military casualties. A great saving of hospital space, equipment and manpower was thus effected. Military patients were admitted to emergency scheme beds as and where they were required, and in the main base hospital blocks of 300 or more beds were allotted for military needs. These hospitals were organised and equipped for civilian casualties and staffed by civilian doctors. As a result, when the Army had to expand greatly in numbers, and very rapidly, it was largely relieved of the burden of matching this expansion with an equal growth in hospital services.
This position, whereby in Britain economic use was made of the available pool of hospital resources, was not the result of any clear-cut decision by the Government. It was the kind of war that was
expected that led to this development. The immense hospital provision thought necessary for civilian casualties contributed to holding up the pre-war Army programme for hospitals, and when the war did come, and there were no civilian casualties but a considerable number of sick soldiers, it was only reasonable to place empty beds and unoccupied staffs at the disposal of the Service departments. The development of hospital arrangements from 1940 onwards for the Armed Forces—abroad as well as at home—is, however, the concern of the Medical History. This brief reference to the subject has only been made to explain how it happened that sick and wounded soldiers came to be admitted to hospitals provided for civilian casualties.
At this point it is necessary to restate in broad terms the main hospital problem. It has already been shown that the kind of war that was expected moulded the size and structure of the emergency hospital scheme within the limits prescribed by available resources. It also determined the purposes of the scheme, the way in which it was administered, and the nature of its relationship to the civil defence organisation. By the end of 1939 a large measure of unity had already been achieved; that is, unity of direction from the centre of Government, unity of regional and local operational control through medical officers and, in certain respects, a common policy throughout the whole country concerning the admission of civilian victims of air raids, other patients transferred to keep beds free for casualties, and the sick and injured from the Armed Force. These were substantial achievements by Government departments who, apart from the Ministry of Pensions and the Service Ministries, were unversed in the problems of hospital management.
But, from a practical angle, these gains were not worth much without the concrete provision of three elementary needs: adequate quantities of hospital beds available in the right areas and in the right numbers; a sufficiency of medical and nursing staff distributed in relation to the beds; a satisfactory supply of hospital furniture, bedding and equipment. Before these needs could be properly met there was one vital question which had to be answered. How many hospital beds would be required for the victims of air raids? Or, to put it in another way, how many casualties would need treatment in hospital beds?
This question is, in effect, a repetition of similar ones asked in chapters I and II. It was there shown that several departments and an assortment of committees made a variety of estimates during the nineteen-thirties. They all employed a simple but, it seems, a fallacious multiplier,18 and all the sums reached astronomical proportions.
One Committee of Imperial Defence sub-committee assumed (in 1937) that if air attacks lasted sixty days there might be 1,200,000 injured persons.19 Other calculations, made in the Home Office and the Ministry of Health, led to an estimated need of 1,000,000 to 2,800,000 beds according to the length of stay of patients in hospital.20
Such figures as these simply had to be rejected as wildly impracticable by the Ministry of Health when that Department assumed, in 1938, the responsibility of organising a hospital scheme. In rejecting them, not only because of the physical impossibility of providing an immense number of additional hospitals, but because of the limitations imposed by the existing pool of trained doctors and nurses, disbelief of the Air Ministry's estimates was, for the first time, frankly expressed in the new hospital division. It was asked whether, with casualty lists of this order, it would be possible to continue a war. These views were not communicated to other departments, nor did the hospital division feel competent to dispute with the Air Ministry. But the advice of the Minister for the Coordination of Defence was sought, and his answer was to repeat the latest Air Ministry calculations of Germany's striking power, and to report that the Home Office was working to an assumption of seventy-two casualties per ton of bombs.21
The employment of this ratio in 1939, when translated into hospital provision, meant an enormous number of beds. Even when it was assumed that each bed would not be occupied for very long, the total number of beds required for air raids casualties alone reached 430,000 by the fourth week of war. If several areas of the country were attacked at the same time as London this scale of provision might have to be repeated more than once. It was also realised that war on civilian society would not take the form of an organised battle front with lines of communication and 'back areas'. The recognition of this fact caused much anxiety in the Ministry of Health and the Home Office. It mad it difficult to decide where to start planning, and in practice it usually meant that departments found it easier to concentrate exclusively on the problem of London.
Moreover, this estimate of 430,000 beds by the fourth week of a war left out of account the needs of the normal sick, and the demands of the Armed Forces for hospital accommodation for their sick and wounded. A review of the situation prepared for the Cabinet in March 1939 showed that there were only about 80,000 beds in England and Wales which could be used for the prolonged treatment of casualties. In Scotland, the position was more unsatisfactory. By various expedients; the ruthless ejection of the sick, the crowding and
transference of existing patients, severe restrictions on fresh admissions of sick people, and by improvising institutions not at the time equipped for surgical work, perhaps 200,000 to 300,000 beds could, it was thought, be temporarily provided.
In March 1939 the Government's reaction to the dilemma was something like this: it is an unmanageable problem; it is no use aiming too high, however, because even if sufficient beds were provided there are not nearly enough trained doctors and nurses and, in any event, only a little money can be spend. Therefore, the best that can be done in the time available is to provide as many beds as possible, and to employ a variety of expedients to increase and improve hospital accommodation.
A special Cabinet committee, established to consider emergency hospital organisation, decided in April 1939 that the maximum effort of which the country was capable was the provision of 300,000 beds for air raid casualties in Great Britain. This was the target, the first specific one set, at which the Ministry of Health and the Department of Health for Scotland had to aim.22
How was this need to be met? In what way, and how soon, could these beds be made available? Behind these questions there were, it was seen, two main tasks: to expand the quantity of hospital accommodation in the country, and to raise the quality of the services provided. But before these could be successfully tackled it was essential to know a great deal about the country's existing hospitals; how many beds there were in different classes of hospitals, how they were staffed, what needs there were and so forth. The Ministry of Health lacked much of this information. Very little was known, for instance, about conditions in voluntary hospitals was scatter and inadequate. In August 1939 the Director-General of the emergency medical service wrote: 'Prior to the repeated surveys which have been made by the Ministry of Health during the past eighteen months there was little appreciation of the low standard of hospital accommodation
in the country as a whole. Even those institutions, that are wont to be regarded as the centres of enlightened treatment and teaching in our large cities, are with few exceptions structurally either unsafe or woefully antiquated'. There were some very good reasons for this lack of knowledge, and some not so good. The multiplicity and types of voluntary hospitals was one for which the Ministry could not be blamed. Nearly 200 out of approximately 1,030 of these hospitals did not even furnish The Hospitals Year Book for 1939 with elementary information.23 The results of the public health surveys of municipal institutions carried out by the Ministry during the nineteen-thirties were never centrally collated or systematically recorded. At many hospitals of all classes, clinical records and collected statistics were either 'sadly lacking'24 or 'so perfunctory as to be practically worthless'.25 A report published just before the war summed up the position quite bluntly. After describing the attempts made by an inter-departmental committee to find out what happened to certain types of patients in hospitals and after they were discharged, it was said that the 'difficulty of obtaining exact statistics of the cases treated in our hospitals is somewhat remarkable'.26 'If it has been difficult,' the report went on, 'to obtain accurate information with regard to the number treated, it has been even more difficult to obtain information as to the results of treatment'. The Ministry of Health, when it took on the task of organising a hospital service for air raid casualties, was greatly handicapped by the lack of much vital information about hospitals and their patients.
Surveys were therefore carried out during 1938–9 by medical officers of the Ministry which aimed at filling some of the gaps in knowledge. The collection of the facts was an essential prerequisite to the planning and organisation of the emergency scheme. At the time, however, these surveys were made the problem of quantity overrode other considerations. Before the war, the Ministry did not fully realise all the implications of the second task—the problem of quality—that lay before it. There were at least four reasons for this. First, the sheer physical problem of providing 300,000 beds for air raid casualties dominated the picture. Second, the Ministry could not know that
the war—if and when it came—was going to develop in the way it did. Third, the voluntary hospitals were self-governing institutions, and the Ministry knew very little about their work. Fourth, the department, because hitherto it had been a supervisory and not an executive department, set out with only a limited knowledge of how hospitals worked and how they should be run.
Hospitals before the War
What were, then, the standards prevailing before the war? What was the size, as well as the character, of the problem that confronted the Ministry of Health during the fifteen months before the outbreak of war when the emergency hospital scheme was being planned? In the following pages an attempt is made to answer these questions. The information possessed by the Ministry in 1939 is reviewed, and to this is added some new material gathered from research and the results of investigations undertaken between 1939 and 1945. Against this background of the hospital situation before the war it will be possible later on to get a clearer idea of what was involved in the planning and development of a wartime hospital scheme. And, later still, it will also be possible to measure some of the achievements of the Government during the war in improving and extending the hospital resources of the country.
The dominant feature of the pre-war situation was the existence of two distinct and contrasting hospital systems—voluntary and municipal. Both had grown up without a plan. Their origins and histories were dissimilar; they were differently organised and financed and, in some respects, they catered for different sections of the population. Of all hospitals in England and Wales,27 less than half the number, and less than one-third of the total beds, were under voluntary management; the rest were controlled by local authorities.
The Ministry faced a rigid and conservative institution. First, on the one hand, there existed a multiplicity of individualistic voluntary hospitals, ranging from the great teaching hospitals to the small, debt-ridden institutions sometimes over-proud of their operating
theatres but often short of surgical specialists.28 Secondly, on the other hand, there were the local authority hospitals, tied to out-worn boundaries, receivers of all the unwanted and uninteresting 'chronic' cases, still flavour with the stigma of the poor law, the often badly equipped and accommodated in large, prison-like buildings, Somehow or other the Ministry had to bring together these rival systems, and to create, out of 'the varying and independently provided hospital facilities',29 a national organisation for the care and treatment of air raid casualties.
Within each of these systems there were remarkable differences. The ancestry of a few of the voluntary hospitals could be traced back to medieval ecclesiastical foundations, but the great majority had come into being during the last two hundred years. Some were largely charitable, while other were chiefly financed by weekly contributions from certain groups of workers; the miners of South Wales, for example, mainly provided some of the hospitals in that part of the country. The evolution, then, of a thousand and more voluntary hospitals was very diverse, their standards of performance, their staffing and equipment, and their debts and endowments varied immensely in 1939. They included both the relatively few world-famous teaching hospitals with 800 or more beds and a complete armoury of special departments and the tiny cottage hospitals with next to no specialist staff. Of about 700 general (all-purpose) voluntary hospitals only some seventy-five were equipped with over 200 beds, some 115 provided between 100–200 beds, over 500 had less than 100 beds, and more than half of these had less than thirty beds. Even in the counties of London and the south-east forty-four percent of the voluntary hospitals had fewer than fifty beds.30
Because of their larger size and greater number of beds the general hospitals and institutions provided by local authorities formed—in terms of accommodation—the backbone of the emergency hospital
scheme.31 A substantial number of these institutions had developed from the early poorhouses where those without means were made to work under harsh conditions. Originally, these institutions had not been provided for ill people; but with the passage of time they became more and more responsible for the old and destitute sick, for chronic, incurable and senile patients. This, their main function in 1939, was left to the by the voluntary hospitals.
There is much evidence concerning the selection of patients by voluntary hospitals, the resulting accumulation of particular types of sickness and groups of people in publicly owned institutions, and the ill-effects of segregation.32 A report issued by King Edward's Hospital Fund and the Voluntary Hospitals Committee for London drew attention to the practice whereby voluntary hospitals exercised 'their discretion over the admission of these patients (the chronic sick) and having admitted them transfer them to municipal hospitals'.33 During 1935–7 some 27,000 patients were transferred by voluntary hospitals to general hospitals provided by the London County Council.34 This practice meant for many old people—particularly in the provinces where hospitals rarely touched the high standards achieved by London—a sentence of death. The municipal hospital or institution often became known as a receiver of incurables, and those that entered its doors felt that they were being 'put away'35. They were certainly neglected in many instances, for the hospital survey report for Eastern England spoke of 'the masses of undiagnosed and untreated cases … which litter our public assistance institutions',36 while from South Wales it was reported that 'many are bedfast for lack of attendants'.37 Almost without exception, accommodation for these chronic sick (including large numbers of people with cancer) was available only in public assistance hospitals and institutions which often did not provide 'either the physical or mental amenities to be found in even the most ordinary well conducted domestic
swelling'.38 A departmental survey of public assistance institutions in a county within fifty miles of London described them, just before the war, as 'pesthouses'.
After the passage of the Local Government Act of 1929 empowering the major local authorities to appropriate public assistance institutions and to enter the field of general hospital provision, the difference in standards and performance of work among municipal hospitals widened considerably. This new function was not a statutory duty. In consequence, some authorities forged ahead and provided first-class hospitals with a complete range of specialist departments and staff, while other authorities were content to maintain their institutions as poor law infirmaries. In one county near London, described in an official report as feudal and parsimonious, the word of one or two local people was often more powerful than the council itself, while in a south-western county the nursing staff of public assistance institutions had to start washing the inmates at three to four o'clock in the morning because they were so short-handed. In seven out of fifty-two institutions admitting sock persons in the south-west region not one trained nurse was employed.39 Over the whole of England and Wales some 70,000 beds in 140 hospitals were being maintained under public health powers just before the war, while nearly 60,000 more in 400 hospitals and institutions were still administered under the poor law.40
These were some of the factors which had to be taken into account when the emergency hospital scheme was organised. But they were by no means the most difficult ones. The age, structural condition and equipment of a large number of municipal—and voluntary—hospitals was unsatisfactory. 'Considering the high place which England takes in the medical world, perhaps the most striking thing about them is how bad they are in this respect.'41 Many of the country's hospitals were erected for other purposes and at a time when idea about the treatment of disease were quite different from those prevailing in the nineteen-thirties. This fact was not disputed by the hospital surveyors. One report after another spoke of large old-fashioned wards, out-of-date kitchens, poor and insufficient equipment, inadequate or non-existing laboratories, ugly prison-like
buildings and old and dilapidated structures.42 Complete statistical evidence is hard to come by since—so far as the writer is aware—no systematic or comparative survey has been made of the age, layout and design of the nation's stock of hospitals. However, for South Wales a good deal of data is available, and although it may not fit the facts of some other areas, it may be accepted as significant. Of twenty-one institutions for the chronic sick existing on the even of war in South Wales and Monmouthshire, nine were over 100 years old, eight over fifty years and two more than forty years old, while the remaining two were put up in 1904 and 1908. All were built as workhouses for paupers. They surveyors classified as hospitals (voluntary and municipal but excluding tuberculosis and mental institutions) and found that, out of a total of 7,945 beds, 3,855—or nearly one-half—were in premises graded as totally unfit to be used as hospitals.43
But these considerations of structure, condition and equipment were overshadowed by the crucial problem: number and quality of the medical and nursing staff. For a good doctor can, in an emergency, overcome material deficiencies, while a bad doctor will still be a bad doctor however excellent the hospital and its equipment. The organisers of the emergency medical service foresaw in 1939 an acute shortage in quantity; there would not be, if the expected number of air raid casualties materialised, enough doctors, specialists, nurses and hospital technicians. There was less recognition then of shortages in relation to the existing needs of the sick population. By 1945, however, there had developed a keener perception of how serious had been the medical and nursing deficiencies before the war.44
Part of the explanation of these pre-war shortages was to be found in the way medical resources were distributed. A few areas of the
country and a small section of the people were abundantly served with medical and nursing skill, but in many places, especially the economically depress areas, there were widespread shortages. This was very true of expert medical skill.45 'The tendency for consultants and specialists to congregate in the county of London is largely a by-product of the past practice of unpaid hospital work, though strengthened in this instance by the standing of the principal London hospitals and the popular respect for a Harley Street address.'46 The 'gross overcrowding'47 of the London specialist population was also accompanied by an abundance of general practitioners in the well-to-do and supposedly healthier districts. Before 1939 there were, for example, proportionately seven times as many general practitioners in Kensington as in South Shields.48
The uneven distribution of medical skill in relation to needs was made worse by another characteristic of the pre-war hospital services: an uneconomic distribution of cases to beds. A complicated case would often receive treatment in a hospital would neither the staff nor the equipment to treat it, while a simple case would occupy a bed in a hospital with a high standard in staff and equipment. The tendency of some consultants to maintain personal waiting lists while others had vacant beds presented a problem of a rather different order.49 Thee was indeed much misdirected and unutliised skill and devotion. The coexistence of two hospital systems was one of the fundamental causes; others can be sought in the way voluntary hospitals selected their sick people and municipal hospitals rejected patients living outside their districts. Yet another was traceable to an uncoordinated and parochial ambulance service composed of many different types of ambulances equipped with stretchers which were not interchangeable.
All the evidence that had accumulated by 1945 showed that there was a general shortage of hospital beds for sick people before the war. The deficiencies were even more serious in respect to certain groups of patients and for particular diseases and injuries. Many of these
special needs were precisely those which became important during the war, for instance, chest surgery, orthopaedic and fracture cases, plastic surgery, skin cases, tuberculosis and maternity provision. From the survey reports of 1945–6, initiated by the Ministry of Health as an aid to reconstruction and supplying for the first time a comprehensive view of the nation's hospitals, there emerged a total retrospective assessment of the needs that had existed in 1939, though many of them were not recognised then. When war broke out, the civilian population were short of hospital beds by about one-third—or roughly 98,000 beds for acute general maternity, tuberculosis, infectious disease and chronic sick needs.50 It was on top of this 'normal' shortage that the abnormal wartime shortage—an immense one, according to all current forecasts—would be imposed.
Pre-war deficiencies in hospital accommodation—both for general and special needs—were due to a variety of causes. Some of these, such as maldistribution of consultants and the restrictive practices of voluntary and municipal hospitals, have already been mentioned. Others were to be found in a shortage of nursing staff, to defects in the organisation of hospital work, to lack of proper equipment, and to the tendency for beds in large hospitals to be allocated to separate units or firms, working more or less independently.51 Above all, many voluntary hospitals were facing financial crises, while local authorities had entered the field of general hospital provision at a time when financial economy was the watchword. Apart, therefore, from a few of the wealthier local authorities, municipal hospitals were, up to the outbreak of war, short of money. That is one reason why, when the time came to organise the emergency scheme, many municipal hospitals and public assistance institutions were found to contain in their general wards an unholy and unhygienic collection of nursing mothers, infants with gastroenteritis, healthy newborn babies, and aged and chronically sick women.52
These than were the kind of problems which the Government faced when the planning of a wartime hospital service began. This was the basic stuff, which could not be swept away overnight and replaced with brand new hospitals, new equipment and new staffs.
All these problems, the inconsistencies, the rivalries, the boundaries and the defects to be studied and understood if, out of the medley, a nationally integrated hospital service for casualties was to be created.
Six year later, a survey of the hospital services covering only the best equipped and wealthiest third of the country's hospitals summed up by saying: 'The general conclusion to be drawn from all this evidence can only be that either in quantity or quality deficiencies in all types of accommodation were widespread in 1938'.53 So far as the whole of the country was concerned, it is highly probable that, on any given day during 1938–9, there were over 100,000 people waiting admission to voluntary hospitals.54
From Plans to Preparation
From what has been said it should be clear by now that up to the outbreak of war the hospital services were, to use the words of the 1944 White Paper, 'many people's business but nobody's responsibility'.55 In accepting the task of organising a national hospital service for air raid casualties the Government had now to take a hand in the business. How was it to be done? To put the question more concretely, and to deal first with the problem of quantity, how was it proposed to provide 300,000 beds
Broadly, the problem was attacked in four ways:
- By the clearance of patients from some existing hospitals.
- By crowding beds together and by providing additional beds in some existing hospitals.
- By improving ("up-grading") many hospitals through the provision of surgical appliances and other equipment.
- By the erection of new accommodation in the form of hutted annexes or hospital hutted units.
The accomplishment of this programme meant telling each individual hospital—and there were 2,378 in the scheme on the
outbreak of war56—exactly what its functions were to be in relation to the purposes and organisation of the scheme. Each hospital had to be fitted into the general plan. The main burden of prolonged care and treatment of patients was to fall, first, on advanced-base hospitals on the outskirts of London and other large cities and, second, on base hospitals in the country. The chief duty of hospitals in London and other vulnerable areas would like in the initial reception and classification of casualties. Patients would then be transferred to hospitals further out. At all hospitals concerned a large number of sick people would, therefore, have to be transferred or ejected on the outbreak of war. Medical and nursing staff, as well as some of the X-ray and therapeutic equipment, would also have to be moved away and hospitals in the vulnerable areas.
These hospitals in the centre were accordingly affiliated to others outside the towns for the double purpose of mutual assistance and to facilitate the transfer of patients. At the same time, all voluntary and municipal hospitals were classified and graded according to the way in which they could be serve the scheme.57 This was important, for it
determined how far upgrading or crowding could provide improved services to make room for more patients.
When the target of hospital accommodation had been set, the purposes of the scheme laid down, and a policy of hospital classification settled, the next stage began of building up the organisation to control and direct the service. To do this meant, in effect, lowering the barriers between the two hospital systems. One of the earliest steps taken by the Ministry of Health was the appointment, in June 1938, of regional hospital officers. Their chief duties were to plan, coordinate and organise the hospital services in the region and, in the event of war, to exercise general control over operations. In each county and county borough medical officers of health were asked to act as their agents. These medical officers were also to be responsible for the administration and operational control of the casualty services58 under the general direction of the air raid precautions controller.
During 1939 the hospital officers were busy on the work of classifying, grouping and upgrading hospitals. In affiliating hospitals to each other, and in grouping them geographically for making easy the flow of patients, the Ministry tried, as far as possible, to ignore differences in hospital government. The basis of the scheme was the linking of casualty hospitals in the danger areas to each other and to the appropriate institutions outside these areas. This would make it possible to send air raid victims to any of the inner casualty hospitals irrespective of their voluntary or municipal status and, subsequently, for patients to be evacuated to affiliated institutions in outer areas again regardless of hospital ownership.
For London, this plan was carried further, partly as a result of recommendations made by a special advisory committee. This body, set up in May 1938 under the chairmanship of Sir Charles Wilson (later Lord Moran), produced in circumstances of urgency an interim plan for a London scheme.59 The Ministry, in formulating its scheme, adopted some of the committee's proposals. London region was divided by the Ministry into ten sectors radiating from the centre, the idea being to evacuate casualties outwards along each sector. The boundaries of these sectors were drawn far beyond the boundaries of the London defence region because it was considered that to drain casualties away a wider area was essential. The hospitals in the inner part of each sector were affiliated both to each other and to the hospitals in the outer part.
The London hospital region, unlike the other regions, was administered directly from the Ministry of Health's headquarters. Each sector had at its apex one or more of the teaching hospitals, and each had its own sector group officer who was responsible to the hospital officer for the whole region. Representatives of the London teaching hospitals—nominated by the hospitals themselves—were appointed sector officers. They were later joined by lay sector officers and sector matrons from the voluntary hospitals. The task of the lay officers was to organise non-medical matters involved in the dispersal of hospitals, and the task of the matrons was to plan the distribution of nursing staffs. On the local government side, hospital liaison officers (including lay officers and matrons) were appointed by the authorities concerned. Each London sector, with its own office and clerical staff provided by the Ministry, was organised in this way. For the rest of the country the arrangements in each region were less complicated, control of operations resting with the regional hospital officer.
Apart from these hospital officers who were officials of the Ministry, most of the other controllers and administrators (both medical and lay) were not permanent civil servants. They were not in any sense mere figureheads or formal advisers. To a large extent they exercised control and helped to shape policy. The appointment of such medical men to share in the work of organising and operating a State service was, at that time, a novel development. But, in the circumstances of the day, no other course was open to the Government, short of taking over all the hospitals in the country for the duration of the war and turning doctors and nurses into salaried officials.
At the time, the Ministry of Health simply had not a sufficient number of qualified people on its establishment to run the emergency hospital scheme. There was, it was admitted, an 'acute shortage of medical staff' in the Ministry.60 Therefore, the trade, so to speak, had to be brought into the department—just as it was in other Ministries, like Food and Shipping. This was, perhaps, the only way in which the cooperation of the voluntary hospitals could be quickly secured. The result was an elaborate administrative structure for London, somewhat out of keeping with the kind of war that was expected, embodying a it did a dual system of voluntary and municipal representation, a nicely calculated balance of medical, lay and official interests, a multiplicity of committees and several complicated chains of responsibility.
To sum up, the emergency scheme, as it finally emerged by the end of 1939, was so arranged as to disturb the status quo as little as possible, while aiming at the maximum pooling and redistribution of hospital resources.
Formulating a scheme was one thing; to get it understood, approved and operated was another. To illustrate from London: the London sector plan took shape only be slow degrees, for it first had to be acceptable to the voluntary hospitals. These institutions were nervous of the Government's intentions, for they had never before been organised on a national basis, and they feared that their independence might be jeopardised if they took part in the scheme. To complicate negotiations further, it was some time before various jealousies among the hospitals themselves, particularly a conflict of views between the lay and medical elements, were resolved. The question of finance, of how much the Government was to pay the voluntary hospitals for their services, was also a sore point. There was a delay—which naturally invited criticism—before the Ministry of Heal received Treasury authority to announce its financial proposals. And when the Ministry did open negotiations with the British Hospitals Association in June 1939 the terms put forwards were not generally welcomed.61
It has been shown that the Government proposed to find the vast majority of beds for air raid casualties by discharging patients to their homes, and by crowding other patients together and thus giving room for extra beds to be introduced. This apparently easy task was not as simply as it appear on paper. It demanded a great deal of work before an emergency hospital service could be said to exist. At the time of the Munich crisis in September 1938, three months after the Health Departments had been put in charge of hospital organisation, detailed plans—quite apart from the actual provision of all the extra equipment that was needed—had not been made. A number of officials were at work, there was some hurried ordering of beds, mattresses, blankets and other equipment, some stretchers and pillows were borrowed from an army depot,62 railway parcel vans were turned into ambulance trains and a start was made in converting coaches into ambulances.
Even after the crisis was over it was some months before the main principles of the scheme had been agreed with all the interests concerned. Then began the stage—from about March 1939 onwards—
of working out their practical application. Viewed as a whole, this was a heavy task the detail of which is described at length in the Medical History of the War. The following list of the more important items of work serves to indicate, however, the formidable nature of the problems which faced the organisers of a hospital service for air raid casualties:
- The carrying out of protective measures at hospitals, such as the provision of shelters, the bricking-up of operating theatres, sandbagging and the improvement of fire-fighting appliances.63 By the end of 1939 work of this kind had been authorised—and in many instances completed—for some 650 hospitals.
- The adaptation and improvement of hospital buildings, including the installation of operating theatres, X-ray rooms, laboratories, dispensaries and stretcher lifts, and the improvement of sanitary and kitchen facilities, lighting and heating. By the outbreak of war about 150 hospitals had been selected for this work of upgrading, and much of the essential engineering had been done, but more than half the programme remained to be completed.
- The organisation of a centrally directed transport service for moving patients from hospital to hospital. This mean the provision of a new inter-hospital ambulance service and, for moving patients long distances, casualty trains.
- The organisation of a network of casualty bureaux throughout the country for the collection and circulation of information concerning admissions, casualties, deaths, discharges, vacant beds, class of patients and so forth. Casualty record forms were not, however, distributed to hospitals until the end of August 1939, and the bureaux were not completely established until after the outbreak of war.64
- The provision of an emergency public health laboratory service, and the expansion and improvement of pathological laboratories in many areas of the country. The task of organising the emergency service was assigned to the Medical Research Council.65
All these measures were vital parts of a wartime hospital service, made all the more necessary because of the deficiencies revealed by the Ministry of Health's surveys and inspections during 1938–9. There were, in addition, a variety of ancillary services, no less difficult to
organise and no less essential, which were either in process of formation during 1939 or else came into being later. Advances in the technique of transfusion, and the knowledge derived from the use of the blood bank in Spain during the civil war, made possible the organisation of a blood transfusion service, for instance, as part of the emergency scheme. It was estimated from experience in Spain that some ten percent of casualties might need blood transfusions. The immense number of expected casualties made it imperative therefore to resort to the storing of blood. The London area was the first to benefit, for the Medical Research Council began to organise a service of stored blood in 1939. Extensions to other parts of the country, through the setting up of regional centres, came later.66
The development of the hospital scheme and its ancillary services during 1939 was fashioned by expectations of the kind of war that might be unloosed on civilian society. This was clearly reflected in the early establishment of neurosis centres and the emergency laboratory and blood transfusion service for London; in the importance given to the organisation of inter-hospital transport, casualty trains and casualty bureaux, and in the issue of burial forms and advice on the disposal of the dead. In conformity, too, was the emphasis on first aid, with doctors in charge of posts and mobile units, to prevent the hospitals from being swamped with patients, on the provision of special services for gas decontamination, and on the organisation of over one hundred ambulance ships, patrol craft and speedboats for the purpose of picking up casualties in the Thames riverside areas and conveying them to the nearest point at which treatment was available.67
All this did not represent a comprehensive medical service; in the beginning the scheme was an elaborate organisation for collecting a large number of casualties, giving first aid, blood transfusions and surgical treatment to the wounded, cleansing the gassed and burying the dead. It was believed that in the first few weeks of war it would not be possible to sort out and classify patients according to the type of injury sustained; mass handling with no differentiation would to be the rule.68 Only one exception to this principle was admitted. Certain hospitals and institutions around London were to be emptied so that special centres could be set up to deal with the hysterical and the neurotic. These centres, where the practitioners in neurology and psychiatry could work, were planned and brought into operation in
advance of other special centres such as those providing treatment for fractures, burns, and head and chest injuries. And in addition to the neurosis centres, mobile teams of 'neuro-psychiatrists' were to visit any casualty hospital to which a specialist had not been attached. The deeply held fear that public morale might crack under the strain of air bombardment was responsible for the early preparation of these services.
The point has now been reached where it becomes necessary to look at the totals of estimated demand and supply for casualty beds, and then to consider the special measures taken during the last few months of peace to staff and equip the hospitals in preparation for war.
A target of 300,000 beds for air raid casualties had been set by the Cabinet in April 1939.69 When this decision was reached, it was estimated that there were, in England and Wales, approximately 500,000 beds (or rooms for beds) in existing hospitals and institutions which could be used as hospitals.70 It was further estimated that, of this number, 100,000 beds could be provided for casualties by upgrading hospitals, by sending home patients fir to be discharged in an emergency, and by the use of the margin of empty beds which normally existed. Another 100,000 were to be provided by crowding and the introduction of additional beds, while a further 50,000 could be obtained in an acute emergency, it was though, either by another measure of crowding or by the use of hospitals in the inner areas of London which could be emptied of their existing patients.
By these measures, which, incidentally, entailed the use of much inferior accommodation, it was calculated that 250,000 beds would be available—about 200,000 of them in the first twenty-four hours of war war. But even this number, inadequate as it was judged to be by the volume of casualties expected, could only be purchased at the cost of ejecting some 100,000 patients and the removing to other hospitals as further 40,000 or so.71 To make up the deficiency of 50,000 beds it was decided to embark on a programme of hutted annexes. As far as possible the huts were to be attached to existing hospitals in order to share administrative quarters and to economise staff and equipment.
The first practical step towards providing these hutted annexes was taken in March 1939 when the Ministry of Health approached the Treasury. The Ministry thought at least 80,000 beds in hutted hospitals should be budgeted for, partly to allow for some accommodation
for sick civilians after the outbreak of war. Despite a reluctance to spend money on schemes which would not, it was thought, be required of the war did not materialise the Treasury agreed to a start being made on a programme of hutted accommodation to provide 40,000 beds.72 By July 1939 the Ministry had decided on the sites for the huts, and it was expected that the scheme would be completed by the end of October.73
The problem of staffing all these extra beds in the casualty hospitals, the upgraded and crowded instructions, and in the new hutted annexes was a formidable one. Additional numbers of doctors and nurses could not be produced at once, nor could they be moved about the country as easily as surgical equipment or bedsteads. Medical and nursing manpower was seen as the central problem and, in many ways, it was the chief factor in determining the size of the Government's programme of hospital care for air raid casualties. It was evident that there would have to be a considerable diversion of staff from the work of treating sick people, especially as there was a call for doctors and nurses from many quarters—the Armed Forces, medical boards under the Military Training Act, and first aid and ambulance work. All this was abundantly clear many years before 1939,74 but no concrete steps were taken to enlarge the professions either on account of future needs or to meet the shortages that existed at the time.
A study of the policies adopted during the war for distributing doctors among the various claimants demands careful treatment including an analysis of the use of doctors in the Services and elsewhere. The present book cannot, however, undertake this highly technical task. What it does offer is the bare minimum of fact necessary for understanding the staffing of the hospital scheme.75
To provide doctors for the scheme, sufficiently mobile for the purposes of casualty work, it was decided in 1938 to enrol a corps of medical men to be known as the Emergency Medical Service. These doctors, ranging in status from house officers to specialists, were to serve in voluntary hospitals and were also to reinforce the full-time salaried staffs of local authority institutions. The proposals of full-time employment in voluntary hospitals raised many difficult issues, as moist of the existing staffs were honorary and part-time. After protracted discussions with the representative bodies the salary and grading of full-time officers was worked out by August 1939. Despite the difficulties of employing these officers in voluntary hospitals it was decided that the terms of service should require whole-time work. It
was thought essential, in the conditions envisaged, that the majority of the doctors enrolled should—as in the Armed Forces—be employed on the basis. Moreover, uniform conditions were necessary as those who enrolled would be liable to serve in any hospital in the country irrespective of whether it was a voluntary or municipal institution. Whole-time officers were also under an obligation to serve, if required, for the duration of the war, and an undertaking was given to guarantee them employment for one year (subject to approved service and the continuation of air hostilities). Although employed and paid by the Ministry of Health these doctors were to work under the general administrative clinical work would not be directed or interfered with in any way by the Ministry.
These terms did not survive for very long. For many reasons, principally aversion to whole-time salaried appointments, they were generally unpopular. The absence of air attacks in the opening months of the war decided the issue, and eventually the Ministry of Health accepted the proposals of the profession itself. The changes, generally from whole-time to part-time status, are discussed in Chapter XI alongside the reorganisation of the emergency medical service which took place at the end of 1939.
In addition to the arrangements for doctors to staff the emergency hospitals, the Ministry also appointed the group officers and a number of consultant specialists in various branches of general medicine and surgery to advise the department on the development of schemes for special treatment centres. Plans, similar to those made for doctors, were also worked out for dentists, pharmacists and opticians.
While these preparations were being made, steps were taken to build up a Civil Nursing Reserve.76 This organisation, established by the Health Departments at the end of 1938, had as its aim the recruitment of at least 100,000 nursing auxiliaries to provide extra staff for the services handling air raid casualties. Those who were not already employed in essential nursing services were asked to join the reserve, and any who lacked experience were given training. By 30th August 1939 nearly 60,000 had enrolled, although only a small proportion were fully trained. In addition, some 24,000 members of voluntary aid detachments were released by the War Office from their Service obligations to help with nursing air raids casualties.
Operational orders for the emergency hospital scheme were drafted by the Ministry of Health as soon as preliminary arrangements could be made for allocating staff to hospitals. On 24th July 1939 instructions were sent out describing the action to be taken on the declaration of a 'state of tension' and a 'state of emergency'.77 On the first
warning, the admission of patients was to be restricted to urgent cases requiring in-patient treatment, daily records were to be started of vacant beds and patients who could be sent home within twenty-four hours, patients fit to be moved to hospitals in the country were to be selected, the additional beds were to be set up and other measures put in hand. On a state of emergency arising, the patients selected were to be sent home or transferred immediately, and staff were to move and report for duty in accordance with arrangements already made.
While all this work of planning hospital accommodation, organising the ancillary services, allocating staff and drafting operational orders was being hurriedly pushed forward during the spring and summer of 1939, attempts were being made to speed up the distribution of extra equipment to the hospitals in the scheme. After hospital space and staff, this was the third of the big problems.
The quantity of equipment needed was immense. Nearly 1,000 completely new operating theatres were installed by October 1939. By the same date, some 48,000,000 bandages, dressings and fitments had been ordered. Close on a million surgical instruments were said to be wanted. The estimated number of artery forceps required represented, for instance, over thirty years' demand for the whole country. The size of the casualty lists that were expected was the factor in creating these great demands. but there were additional reasons, some of which were obvious to the Ministry of Health in 1939, while others did not become apparent until later when Britain's manpower had to be carefully husbanded. Much of the accommodation, and most of the emergency hospitals outside the evacuation areas, such as public assistance institutions, were not equipped to handle surgical cases. This was recognised before the war. To equip them all at once was, therefore, a formidable task. And equipment meant, not only surgical instruments, theatre and X-ray apparatus, drugs and dressings, but beds, blankets, clothing and an immense range of ward, domestic and kitchen appointments. In addition to these institutions and the new hutted annexes which had to be fitted out, it was later found that over a large proportion of the country's hospitals the standard equipment and furnishing was poor, inadequate and often out-of-date.78 This realisation came just at that particular point in the nation's history when the physical difficulties of making better provision were at their greatest.
But this was chiefly a problem of quality. What came first in time, and what distinguished the planning of 1939, was the emphasis on quantity. To the demands that followed from the Government's
decision to provide 300,000 beds for air raid casualties, there had also to be added large quantities of equipment and materials needed for first aid posts, ambulances, casualty trains, laboratories, emergency maternity homes and nurseries, and many other services in England, Wales and Scotland. At the same time, the Armed Force were also out to buy medical supplies and equipment, as well as millions of beds, blankets and items of clothing.
This sudden and vast invasion by many agencies of Government into a variety of trade markets cannot be examined critically in this volume. But it is necessary to point out here one or two difficulties which affected the Ministry of Health and the Department of Health for Scotland. Neither were purchasing departments. Nor was there functioning—at that time—any Ministry of Supply to which these departments could turn for their requirements. At first, in January 1939, it was proposed that the contracts branch of the War Office should undertake the task of obtaining all medical and surgical equipment. But this idea soon had to be abandoned, as the branch was heavily engaged in providing for the expansion of the Army Medical Service.
Eventually it was decided that the bulk of this class of equipment should be purchased through the medical supplies branch of the London County Council.79 It was in this way that the necessary experience of the different trades and the technical knowledge of medical equipment was obtained quickly. Hospital beds, bedding and many miscellaneous items were bought through the Office of Works, nurses' caps and overalls through the General Post Office, towels through the Admiralty and X-ray units and tetanus antitoxin through the War Office.
It cannot be said that the use of the London County Council and other agencies by departments in London and Edinburgh was the speediest or most effective way of obtaining equipment. But it had one advantage, even at the expense of some failure in coordination. It meant that the technical knowledge and experience (which the Health Departments lacked) of one of the largest hospital authorities in the world was immediately available to the Government. Defects in coordinating orders for equipment arose both within the Ministry of Health and between certain departments.80 This was to some extent inevitable. It was part of the price that had to be paid by these Ministries in the process of growing up to become departments fully armed with the knowledge of how hospitals worked.
In addition to these arrangements for central purchasing, quantities of equipment for the hospital scheme were bought locally. Under the provisions of the Civil Defence Act the authorities of certain hospitals were obliged to hold, at their own expense, specified reserves of medical stores, beds and other articles.81 Also, those hospitals where accommodation was to be greatly increased were asked to purchase locally certain items. The cost of most of the additional equipment was met by the Exchequer, either by the provision of equipment on loan or by the reimbursement of approved expenditure. Hospital authorities were expected to arrange, without cost to the Government, for the storage, custody and preservation of a great part of the medical stores and equipment supplied to them.
These authorities were told in detail what reserves to acquire, what should be purchased locally and what items the Government would supply. All this information was contained in circulars issued five days before the outbreak of war.82
Before these circulars were sent out a considerable quantity of equipment had already been distributed to hospitals by the Ministry. There were delays, however, before the machinery of supply was functioning satisfactorily. It took time for a decision to be reached to use the London County Council as a purchasing agency. And it was necessary to survey the hospitals and plan many details of the scheme before starting to work out equipment schedules. Yet another factor, and probably the most influential, was the reluctance to spend money on services which, it was considered, would not be needed it war did not materialise. This attitude, whether justified or not in the political and economic circumstances of 1938–9, affected preparations for evacuation and civil defence just as it impeded the development of the emergency hospital scheme. It did not of course always square with the views that were held of what the war would be like if and when it came.
The first approach to the Treasury for sanction to but surgical instruments, ward furniture and X-ray apparatus was made by the Ministry of Health in February 1939. On 4th April approval was given for initial purchases amounting to £230,000, or one-fifth of the total sum authorised in October 1939. As regards the equally important matter of beds, 50,000 had been ordered in the middle of the Munich crisis in the autumn of 1938, a second order of 50,000 was made at the end of March 1939, another 40,00 were asked for on 1st June and a further 100,000 on 4th August. This made a total of
250,000—all of them iron bedsteads. Only 50,00 had been delivered by August.83 Despite the timber shortage,84 a wooden bed was therefore hurriedly designed for quick production, and contracts were signed for 100,000 five days before war was declared.85
The situation as regards many other items of equipment was much the same. In some instances, such as blankets, the total demand for a variety of emergency services ran into millions. In the early days there was some failure to coordinate all these requirements. Orders were not spaced out evenly, most of them being rushed out during August 1939. One result was that in the first few days of war 100,00 blankets were being hurriedly cut from stocks of men's overcoating.
This last-minute rush for equipment was not exceptional. Under almost every hard of preparation, something similar occurred. There had been, first of all, years of leisurely study which lead to very little action. There followed, from about 1935, the phase of planning which lasted until June 1938, and culminated in the decision to place responsibility for an emergency hospital scheme on the Health Departments. Even then, many facts had to be collected before the principles of organisation and action could emerge. The Munich crisis revealed how rudimentary and inadequate the organisation was, and in the last year of peace there ensued a rush to make things ready.
Yet it had been necessary to pay full attention to the early and middle phases of preparations. In no other way would it have been possible to understand how the emergency scheme took form and then strength of the ideas about the character of a future war which decided its shape. In a later chapter—Chapter XI—the organisation is studied as a going concern before it had to meet the test of air attack. First, however, the following chapter takes a brief look round at the state of preparations for various emergency services on the eve of war.
Contents * Previous Chapter (IV) * Next Chapter (VI)
1 Singer, C. A Short History of Medicine, 1928.
2 Fisher, H. A. L. in his History of Europe, (1936), considered that the work of Florence Nightingale in the relief of human suffering, the raising of the status of nurses, and the improvement in the standard of hygiene was 'one of the few compensations for the waste and havoc of the Crimean War'.
3 Certain subjects, such as treatment at first aid posts and the ambulance services, also the concern of Civil Defence, O'Brien, T. H., (1955).
4 Home Office circular 700216/14, 9th July 1935.
5 In common with other civil defence services as laid down in the Air Raid Precautions Act of 1937. The Government offered a fifty percent grant when financial negotiations were opened with local authorities in the middle of 1937. The history of these negotiations and the settlement of the grant question are the concern of Civil Defence, O'Brien, T. H., (1955).
6 These arrangements followed the recommendations of a sub-committee of the Committee of Imperial Defence appointed in May 1937. The sub-committee did, however, express a doubt as to the feasibility of maintaining a distinction between base and casualty hospitals, and suggested that Ministers should reconsider the question.
7 Chapter IV, pp. 48–9. Sir John Anderson had warned the committee of Imperial Defence, as early as 1928, that 'if any attempt was made to create ad hoc machinery with its own personnel and with a separate Minister to deal with the problem little if any progress would be made'.
8 The first committee set up by the Committee of Imperial Defence to consider 'the coordination of medical arrangements in war' recommended that casualties from the defence force should 'as far as practicable, be admitted to service hospitals and remain under service control'. It was proposed that the Army and Navy should make their own arrangements for additional hospital accommodation while, owing to the wide disposition of Air Force units, provision for their casualties should form part of the general hospital services. These proposals were endorsed by the Committee of Imperial Defence in 1937.
9 When discussions were held with the Treasury, the Permanent Secretary of the Air Raid Precautions Department minuted in February 1938, 'political difficulties might arise if there were much delay in getting arrangements for hospital accommodation settled, more especially as the public would soon realise that little had been done as regards bomb-proof shelters'.
10 Annual Report of Chief Medical Officer of the Ministry of Health, 1938, p. 58.
11 Home Office circular 701649/4, 23rd December 1938.
12 Apart from the organisation of inter-hospital transport. This was in the hands of the Ministry of Health and was not delegated to local authorities.
13 Excluding doctors and nurses for whom the Ministry of Health was responsible.
14 The organisation of the scheme was, in some essential respects, different in Scotland from that in England and Wales. The Scottish Department of Health was not only responsible for controlling the scheme but, during the war, it had the task of directly administering a number of State hospitals. Because of this and other special features and history, in this book, of the emergency medical service relates only to England and Wales. A detailed account of Scottish experience will be found in the Medical History of the war.
15 Memorandum 2, Emergency Hospital Organisation, Ministry of Health, 1939.
16 These functions were provided for in the Civil Defence Act, 2 & 3 Geo. 6 c.31, and under Defence Regulation 32 (made under the Emergency Powers (Defence) Act, 1939) the Ministry of Health was given power to issue directions to hospitals in connection with the treatment of casualties and other classes of patients.
17 See footnote 8 on p. 57.
18 See Chapter II, pp. 12–13.
19 See Chapter II, p. 13.
20 See Chapter II, p. 13.
21 The 'Barcelona' ration. See Chapter II, p. 14. This was in March 1939.
22 This was not the first committee to consider the problem. But this narrative would have been rendered unreadable if it had been burdened with a review of the activities of numerous committees, the results of who work were largely inconclusive. Various committee set up the Committee of Imperial Defence had considered the size of the hospital problem in 1926–8, 1936–7 and 1937–8. But they were all handicapped—like the Ministry of Health—by not knowing with any accuracy the amount of hospital accommodation in the country, its quality, and what scope there was for expansion and improvement. The Air Raid Precautions Department had attempted to collect information, by means of questionnaires, during 1936. But this yielded little that was useful. The Ministry of Health carried out a survey during January to May 1938 which also proved to be of limited value. Another national survey was initiated in September 1938 of voluntary, local authority and mental hospitals and institutions, and this, together with supplementary data from the Ministry's hospital officers, formed the basis of the case put before the Cabinet in March 1939.
23 The Year Book was published in 1941. Seventy-eight voluntary hospitals in Britain did not provide an annual report, while a further 120 failed to 'comply with certain minimum requirements in uniform accountancy' laid down by the British Hospitals Association. In 1938, 1940 and 1941 much the same kind of situation obtained.
24 Hospital Survey of Berkshire, Buckinghamshire and Oxfordshire reporting on the 1938 position, Ministry of Health, 1945.
25 Hospital Survey of South Wales and Monmouthshire reporting on the 1938 position, Ministry of Health, 1945.
26 Final Report of the Inter-Departmental Committee on the Rehabilitation of Persons Injured in Accidents, 1939. Other writers had also drawn attention to the failure of the voluntary hospitals to keep adequate records, namely, the Report of the Voluntary Hospitals Commission (1937) appointed by the British Hospitals Association, and the editor of the Hospitals Year Book in 1940.
27 Excluding mental and convalescent homes and hospitals run by the Defence Services.
28 See Hospital Survey reports on conditions in 1938 (published by the Ministry of Health in 1945–6), especially that for the Sheffield and East Midlands area: '… a striking feature has been the preponderance of surgical work'. 'The Annual Reports of the small hospitals contain lists of visiting consultants and one is led to believe that they all undertake regular work there. It was apparent that the visits of consultants to these small hospitals were relatively infrequent, and some specialists, whose names appeared in the Annual Reports, were never asked to see patients at all', (Hospital Survey of the South-Western Area, report on the 1938 position, Ministry of Health, 1945( This survey also showed that in many of these hospitals the matron was expected to act as the radiographer, to carry out the work of almoner, and to be midwife and cook, in addition to her work as matron.
29 Cmd. 6502, A National Health Service, p. 56, 1944.
30 The proportion of small voluntary hospitals was much more marked in the provinces. Before the war there were, in all, 49 voluntary hospitals in South Wales and Monmouthshire of which five had over 100 beds, 21 had 31–100 beds and 23 had less than 30 beds. In Berkshire, Buckinghamshire and Oxfordshire there were 75 hospitals of all types (voluntary and municipal), 41 of which had less than 50 beds. In addition, there were 89 private nursing homes with an average of less than nine beds apiece.
31 The next few pages refer mainly to general hospitals and not to special institutions such as infectious diseases hospitals, tuberculosis sanatoria, maternity homes, mental hospitals and mental deficiency institutions. All these contributed in varying degrees to the emergency hospital scheme. The problems of adapting, equipping and staffing a mental hospital or infectious diseases hospital, for instance, were just as difficult—if not more so—as conveying and improving a general hospital or a public assistance institution. the pre-war inadequacies of many of these special hospitals were not markedly different from those to be found in the "all-purpose" hospitals.
32 This question is further discussed in chapters XXII and XXIV.
33 Some Aspects of the Post-War Hospital Problems in London and the Home Counties. Kind Edward's Hospital Fund for London and the Voluntary Hospitals Committee for London, July, 1945. See also references in the Hospital Survey reports published by the Ministry of Health in 1945–6.
34 Annual Reports of the Council for 1935–7, Public Health, vol. IV, part I.
35 Memorandum on the Care of the Chronic Sick. The Institute of Almoners, May 1946.
36 Reporting on the 1938 position, Ministry of Health, 1945.
37 Hospital Survey of South Wales and Monmouthshire reporting on the 1938 position, Ministry of Health, 1945.
38 Hospital Survey of the Yorkshire area reporting on the 1938 position, Ministry of Health, 1945.
39 Hospital Survey of the South-Western Area reporting on the 1938 position, Ministry of Health, 1945.
40 Cmd. 6502, A National Health Service, 1944.
41 Hospital Survey of the North-Western Area reporting on the 1938 position, Ministry of Health, 1945.
42 These reports applied not only to all types of voluntary hospitals and to general hospitals provided by local authorities but to mental hospitals, mental deficiency institutions, infectious diseases hospitals, tuberculosis sanatoria and maternity homes. The emergency scheme included all types and particularly the larger institutions whether voluntary or municipal. The Ministry of Health's survey of January–May 1938 revealed great inadequacies in equipment, the South Wales survey showed that only three out of 141 hospitals had staffed and equipped laboratories, while the Eastern and London and South-Eastern area surveys, and many of the Ministry's and convalescent facilities, inadequate pathological and X-ray provision and other widespread deficiencies. The Goodenough report, in reviewing the state of voluntary hospitals, called attention to serious deficiencies in accommodation and equipment in many of the teaching hospitals, (Hospital Survey reports, 1945 and Report of Inter-departmental Committee on Medical Schools, H.M.S.O., 1944.
43 Hospital Survey of South Wales and Monmouthshire reporting on the 1938 position, Ministry of Health, 1945. 'We have seen', wrote the surveyors of the hospital service in Sheffield and the East Midlands area, 'far too many examples of dark, overcrowded, ill-equipped infirmary blocks in which the chronic sick drag out the last days of their existence with few of the amenities of civilised life; (Survey Report on 1938 position, Ministry of Health, 1945).
44 Illustrated in this instance, by a comparison of the language and the standards employed in the White Paper A National Health Service (Cmd. 6502-1944) and in the Ministry of Health's pre-war Annual Reports.
45 Before the war some counties were without a single gynaecologist; the Eastern counties had no thoracic surgeons, dermatologists and paediatricians and only two hospitals with psychiatrists on their staff; in South Wales and Monmouthshire only five out of 56 acute general and acute special hospitals had specialists in continuous charge of patients; in the Sheffield and East Midlands area covering a population of 4,000,000 'paediatrics is a relatively undeveloped subject', plastic surgery was not organised at all, while less than six doctors restricted their work to the administration of anaesthetics. (Hospital Survey reports and Ministry of Health Public Health Survey files).
46 The Hospital Services of London and the surrounding area reporting on the 1938 position, Ministry of Health, 1945.
47 Lancet, 'A Plan for British Hospitals' by its special commissioner, 28th October, 1939, ii, 945.
48 Planning, P.E.P. Broadsheet No. 222, 30th June 1944.
49 Hospital Survey reports published by the Ministry of Health in 1945–6.
50 A summary of the conclusions of the ten Hospital Survey reports issued by the Ministry of Health appeared in The Hospital Surveys (1946), published by the Nuffield Provincial Hospitals Trust.
51 Gardner F., and Witts, L.J., 'Length of Stay in Hospital', Lancet, 1946, ii, 392.
52 A great amount of evidence of these conditions is scattered among thousands of Ministry of Health files, particularly the reports of surveys by medical officers and inspectors from the Ministry. An article in Lancet (1946, i ,841) quoted a description of conditions observed by Dr. M. Warren in one public assistance infirmary: 'In the same ward were to be found senile dements, restless and noisy patients who required cot beds, incontinent patients, senile bedridden patients, elderly sick patients who were treatable, patients up and about all day, and unmarried mothers and infants'.
53 The Hospital Services of London and the surrounding area reporting on the 1938 position, Ministry of Health, 1945. The survey covered London and twelve south-eastern counties with a total population of over 14,000,000.
54 Apart from mental hospitals and mental deficiency institutions. This estimate is derived from summarising the waiting lists reported by the hospital surveys, and by then applying the resulting ratio of waiting lists reported by the hospital surveys, and by then applying the resulting ratio of waiting lists to population to the whole of the country. The figure of 100,000 is probably an under-estimate if reliable figure of length of stay in hospital were known. What pre-war data do exist show that length of stay was often very short, patients being discharged as soon as the acute phase of their illness had passed. Had they been retained, waiting lists would have been longer. See, for example, 'Length of Stay in Hospital', Gardner F., and Witts, L. J., Lancet, 1946, ii, 392.
55 A National Health Service. Cmd. 6502. 1944.
56 England and Wales. As previously stated, this account excludes Scotland. A separate place is given to Scottish experience in the Medical History.
57 Briefly, existing hospitals were classified into the following groups:
- Class 1A hospitals. These included all the larger hospitals, whether in inner or outer areas, which had, or could be given without great difficulty, facilities for dealing with both medical and surgical cases. These constituted the principal casualty hospitals. To reach this standard some hospitals were upgraded by the provision of equipment and, where necessary, by structural adaptation.
- Class 1B hospitals. This group comprised small hospitals and certain special hospitals. They were to be used principally for giving treatment to the less seriously injured, and not as a rule for inpatient care. Many were designated by local authorities as first aid posts.
- Class 2 hospitals. These hospitals were not considered suitable for the initial reception of casualties. They were to be used for convalescent and chronic cases, and for patients not requiring special treatment.
- Class 3 hospitals. Infectious diseases hospitals made up this group. Those not in the areas to be evacuated were to be left to carry on their normal work. This decision was taken because of the fear that the evacuation scheme would place a heavy strain on these hospitals in the receiving areas.
- Special hospitals. These were divided between classes 1 and 2 according to their facilities and the type of work done. In general, they were, as far as possible, to continue with their work while, at the same time, making a contribution to the provision of treatment for casualties.
- Maternity hospitals. These hospitals in outer areas were to be retained for maternity work. In the danger zones, however, it was considered that only emergency and difficult cases could be admitted. As soon as the ordinary work of these hospitals decreased or came to an end they were to be used for the reception of casualties.
- Children's hospitals. It was assumed that evacuation would leave hospitals of this type in the inner areas without much work to do. Therefore, they were to be used for the reception of casualties. Children's hospitals in the outer areas were to carry on with their normal work which would, of course, include the care of child patients transferred from inner areas.
- Mental hospitals. It was decided that mental hospitals and mental deficiency institutions would have to make a considerable contribution to the scheme. Many of these hospitals in country areas were to rearrange the accommodation for their ordinary hospitals in country areas were to rearrange the accommodation for their ordinary patients by crowding-up to make room for casualties in one wing or block which could be fitted to receive them. Certain hospitals were to be completely cleared of their patients—who would be transferred to other institutions—thus providing a number of large hospitals for the reception of casualties and for other purposes.
58 Principally, the ambulance service and first aid parties, posts and mobile units.
59 The scheme was submitted to the Ministry of Health on 20th July 1938. This committee, like so many others, was much influenced by the threat of air attack on London. A great shortage of hospital accommodation was feared, and it was therefore proposed that hotels, schools, private houses and a large number of tents should be used.
60 This statement was made in the Ministry at the end of 1938 in connection with the analysis of confidential reports on maternal deaths.
61 The financial arrangements with voluntary hospitals are discussed in Chapter XXII.
62 The shortage of stretchers in 1938 recalls a similar experience in 1914. The failure to order this equipment before the outbreak of war, commented the medical historians of 1914–18, re-emphasised a lesson which had been learnt a the time of the first Egyptian campaign in 1882 (Official History of the War 1914–18, Medical Services, Vol I).
63 Ministry of Health E.M.S. Memo, No. 1, January 1939.
64 Ministry of Health circular 1847, 25th August 1939, E.M.S. Memo. No. 3, 6th October 1939, and Ministry of Home Security circular 52/140, 21st March 1940.
65 An account of this service is contained in the Report of the Medical Research Council for 1939–45., Cmd. 7355. See also Report of the Chief Medical. Officer of the Ministry of Health, 1939–45.
66 An account of the blood transfusion service is given in the Report of the Medical Research Council for 1939–45, Cmd. 7355.
67 Plans for a River Emergency Service were prepared early in 1939 by the Port of London Authority to provide a casualty service from Hammersmith to Convey Island—a distance of 44 miles.
68 Statement Relating to the Emergency Hospital Organisation, First Air Posts and Ambulances. Cmd. 6061. July 1939.
69 See above, page 64. The figure of 300,000 beds included provision for Scotland. For England and Wales alone the aim was to provide 290,000 beds.
70 Including mental hospitals.
71 In the absence of accurate statistics before the war it was guessed that the hospital population of England and Wales on any given day was about 300,000 (exclusive of mental patients and mental defectives).
72 In addition, 9,000 beds in hutted hospitals were to be provided in Scotland.
73 Statement Relating to the Emergency Hospital Organisation. Cmd. 6061. July 1939.
74 The first sub-committee of the Committee of Imperial Defence to consider the need for doctors in time of war reported in July 1924.
75 For further details see the Medical History of the War.
76 Only brief reference is made in this volume to the problems of the nursing services. The subject is treated at length in Studies in the Social Services, Ferguson, S. M., and Fitzgerald, H (1954).
77 Ministry of Health E.M.S./Gen./231.
78 Some indication of the range and character of these deficiencies has already been given—see pp. 69–70 above.
79 This arrangement held until November 1941 when the Directorate of Medical Supplies in the Ministry of Supply took over the work, and combined the purchasing of medical and surgical equipment for the emergency medical services, the civil defence services and the Armed Forces.
80 An illustration of this is given in the next chapter concerning the demand for blankets by various departments.
81 Civil Defence Act, 1939. Section 51(c) and 55. The requirements amounted to about four weeks' reserve of drugs and other medical stores, one-tenth reserve of beds and mattresses and one-fifth reserve of bedding and ward equipment.
82 Ministry of Health circulars 1849–50, 29th August 1939.
83 H. of C. Deb., 1st August 1939 Vol. 350, Col. 2278.
84 See British War Economy (1949), Hancock, W. K., and Gowing, M. M., Chapter IV, Section iii.
85 The figures given in this paragraph include Scottish requirements.