As we once were The wartime emergency medical service and the future NHS
When Mr Chamberlain announced on September 3rd 1939 that this country was at war with Germany, the Emergency Medical Service (EMS) swung into action. This organisation, which was to influence the future structure of the NHS, did not come ‘out of the blue’ but was the result of considerable hard work, cooperation and negotiation between ministries, local authorities, organisations and the military, starting many years earlier.
Initial ideas about the impact of war on London surfaced in 1926 when a casualty scheme for the City revealed a woeful shortage of ambulances. Furthermore, their designs differed and not all could take standard stretchers. By 1928, the general concept, based on the First World War experiences, was to establish casualty-clearing hospitals in target areas with base hospitals in the country. Casualties resulting from air raids on London would require 36,000 beds.
Further planning followed the passing of the Air Raid Precautions Act in 1937. Much discussion ensued regarding which authority was responsible for what. The 1938 Munich Crisis brought matters to a head and the Ministry of Health took responsibility for hospitals, first aid services and ambulances. The armed services had their own hospitals but with access to civilian facilities. The Ministry realised it had no idea of the number of beds available in the country. The subsequent survey revealed the good news that there were 500,000 hospital beds, of which 130,000 were in mental hospitals. The bad news was that not all were in good structural shape: two-thirds were built before 1891 and nearly a quarter before 1861. Many lacked diagnostic facilities, pathology, radiology and operating theatres while catering and heating required urgent attention. At one London hospital, the legs of the cots in the maternity department stood in tins of oil to discourage the cockroaches from crawling up!
The Air Ministry anticipated that the Luftwaffe would attempt a ‘knock out’ blow in the first few days of war and estimated that about 100,000 tons of bombs would fall on London in the first fortnight of war! A massive number of civilian and service causalities would result - 25,000 casualties per day for the first ten days of war - thus some 300,000 beds would be required in Great Britain.
The Emergency Medical Service
The Ministry’s aims were:
- To create 300,000 beds in hospitals for civilian casualties and all sick service personnel
- To provide outpatient and hospital treatment in casualty clearing hospitals and in fully equipped base hospitals
- To treat certain types of injuries and disease in fully equipped and staffed special hospitals
- To provide adequate accommodation in hospitals for medical and convalescent cases
Two categories of hospital existed pre-war: independent hospitals and those controlled by the local authority with specialist units such as tuberculosis and maternity hospitals. The standards provided by the municipal hospitals varied widely. Some were so short of nurses that they started washing patients before 4am. For wartime purposes, hospitals were classified into two groups: Class 1 would carry out surgery and treat casualties, while Class 2 hospitals would provide convalescence and medical care.
The Ministry accepted that the current number of beds was inadequate for the anticipated casualties, service personnel and the usual range of civilian illnesses. The total would be increased by:
Sending patients home. On the declaration of a state of emergency, all hospitals, even some mental ones, were to discharge those patients no longer in urgent need of hospital treatment as well as moving patients from larger general hospitals in danger areas to more distant hospitals. These moves would free about 100,000 beds within 24 hours. Hospitals had to make their own arrangements to organise appropriate transport.
Additional beds. An extra 100,000 beds were created by ‘crowding’: putting up extra beds into existing wards. Some private homes were equipped and converted for EMS use.
Building hutted accommodation. This would be on existing hospital sites and would provide an extra 40,000 beds. The wards would be 144 feet long and 24 feet wide with kitchen, sluice room, two bathrooms, four WCs, sister’s duty room, linen room and the main ward. This would be 108 feet long and would provide 36 beds. However, if space between beds was reduced to 5 feet then the available space would accommodate 42 beds. This ‘temporary’ accommodation remained in use for many years, as post war doctors well know.
These measures would, it was calculated, provide an extra 290,000 beds. To support the system, casualty bureaux were set up to collect information about admissions, deaths, discharges etc. By March 1941 over 80% of hospitals were included in the EMS scheme.
This was far from the whole story. Many hospitals required considerable modernisation by installing lifts, improving operating theatres, laundries, kitchens and sanitary facilities. They also needed protection from bomb damage. Ground and upper floors required shielding from blast and splinters, while operating theatres required sandbagging against flying glass. Staff needed bombproof accommodation and, if off duty, access to basements, slit trenches or steel shelters. In the event, many hospitals were bombed. Ten London hospitals were evacuated completely due to bomb damage and a further 7 were closed for repair due to flying bomb damage. In total, enemy action destroyed over 4,400 hospital beds.
Inter-hospital transport was needed to move patients quickly away from the centre of attack. For short journeys, the Ministry arranged the conversion of 300 Green Line buses into ambulances with 8-10 stretchers. Outside London, other bus companies converted 500 buses. For longer distances, 340 train brake vans were converted into ambulance trains with 36 stretchers per van.
The Ministry divided the country into regions and appointed one of its medical officers to each. The London region was subdivided into 10 sectors radiating from the centre towards the Home Counties. Each sector had at its apex one or more teaching hospitals, which would triage patients before transferring them to peripheral hospitals. The main teaching hospitals and patients were moved away from the centre: e. g. Guy’s moved to Pembury in Kent.
First Aid Posts. Local authorities provided first aid posts, supervised by the local medical officer of health, and controlled by a local medical practitioner and volunteers. Mobile ambulance parties collected casualties.
Hospital supplies. The government, using the London County Council as agent, purchased large supplies of bedsteads, blankets, mattresses, surgical and hospital equipment, which were stored in regional depots. Hospitals were encouraged to increase and store supplies of drugs and dressings.
Laboratories. The Medical Research Council was made responsible for the organisation of wartime laboratory services. Vaccines and sera were stored in depots in different parts of the country.
Medical personnel. Medical organisations created a register of those volunteering to serve in the armed forces and devised a scheme for a doctor’s practice to be continued by another practitioner. By 1941, over 1,700 doctors were employed full time in the service, with some 560 employed part time and thousands employed on a sessional basis. However, the EMS and the Armed Services were remained short of doctors. In April 1940, all doctors were subject to ‘call up’, medical staff were recruited from the USA and foreign ‘alien’ doctors were registered to work in the UK. The shortage was such that even final year medical students were employed. The Polish School of Medicine in Edinburgh, 1941-1949, was established for Polish medical students who received training from Polish Professors.
Nursing Personnel. Because demand for nurses in 1938 exceeded supply, the Ministry set up a Central Emergency Committee for the nursing profession. It created a register of trained or partially trained nurses who would be available for service in wartime. Large numbers of auxiliary nurses and a special volunteer nursing service would support them.
Operation Pied Piper. The Ministry and the Board of Education were involved in planning the voluntary evacuation of schoolchildren, younger children and expectant mothers from areas considered most ‘at risk’ such as London and the coastal areas of East Anglia and the South Coast.
At the end of the war, the EMS was generally considered a success although mistakes had been made. One was that the sudden emptying of beds in tuberculosis hospitals, which resulted in infected patients returning to the community. Sick civilians paid the price of the success. Mental hospitals became overcrowded. Physically ill patients had to wait for admission, experienced delays in investigations and treatment in spite of empty manned EMS beds.
The number of casualties. Happily, this proved smaller than anticipated but left large numbers of empty staffed beds available throughout the war. As late as March 1944, there were still 40,000 empty staffed EMS beds. Consequently, the Ministry relaxed the rules to allow the admission of sick civilian patients up to 75% of the hospital’s normal capacity.
Displacements. Over 7,600 chronic sick and shelter derelicts, found in public shelters and rest centres in London during the air raid period, were moved to emergency hospitals in the provinces or coastal areas during 10th October–14th November 1940. Similar transfers took place in Southampton, Plymouth, and Cardiff.
Evacuations. Almost 3.75 million people were displaced, with around a third of the entire population experiencing some effects of the evacuation. In the first three days of official evacuation, 1.5 million people were moved; 827,000 children of school age; 524,000 mothers and young children (under 5); 13,000 pregnant women; 7,000 disabled persons and over 103,000 teachers and other 'helpers'. The evacuation procedure partially ceased in September 1944 and ended in June 1945.
Aftermath for the elderly. Elderly and chronic sick patients were evacuated to safer hospitals but were sometimes moved so often that they ended up in institutions akin to workhouses. In 1947, Dr. Sturdee, at the Ministry of Health, reported on the number and condition of elderly patients evacuated from chronic wards of hospitals in dangerous areas to institutions in safer parts of the country.
‘It was something of a shock to find that while the patients were being fed and cared for to the extent of being kept clean and free from bedsores, little or nothing was being done in the way of active treatment or rehabilitation. The common view seemed to be that the patients were ‘chronic sick’, and no treatment would be of any avail. They must therefore be kept in bed until they died, in five, ten or possibly twenty years’ time.’
What was the legacy of the EMS? Notable features included the regional organisations, the relationships between central teaching and peripheral hospitals, and the creation of regional specialist centres, regional blood transfusion and laboratory services. Less well-endowed hospitals benefited from upgrading, opening outpatient departments and the expertise of teaching hospitals. Medical education improved, doctors were able to move more freely between voluntary and municipal hospitals, and medical research stimulated. A wag once said that the Luftwaffe had achieved in months what had defeated politicians and planners for at least two decades!
Dunn Lieut. Col. C. L., The Emergency Medical Services, HMSO, 1952
Elliot Right Hon. W., Medicine and The State. British Medical Journal, 1:911-914, 1945
Ministry of Health, Annual Report of Chief Medical Officer for 1939-1945, HMSO, 1946
Sturdee E. L., Care of the Aged and of the Chronic Sick in Great Britain, Geriatrics, 2: 359-364, 1947
Titmuss R., Problems of Social Policy, HMSO, 1950
 Churchill commented in his usual inimitable manner that: ‘[One] particular night [during the blitz] 180 persons were killed in London as a result of 251 tons of bombs. That is to say, it took one ton of bombs to kill three-quarters of a person’.