As we were in the early post war years - The 1941-1945 hospital surveys
On 9th October 1941 the Minster of Health, Ernest Brown, presented the House of Commons with the general principles on which the government proposed to base its post war hospital policy. As part of the strategy, he was organising surveys of hospital services in England and Wales, which in the event took 4/5 years to complete.
This bold, astonishing, confident action was at a time when the United Kingdom, after two years of war, was in an apparently hopeless state in the Second World War against Nazi Germany. Churchill said in July 1940: ‘Now it has come to us to stand alone in the breach and face the worst that the tyrant's might and enmity can do.’ There had been successes, such as against the KM Admiral Graf Spee, scuttled in December 1939 and, on Churchill’s orders, the captured British merchant seaman placed on board the Altmark were rescued in Jossingfjord by Captain Philip Vian of HMS Cossack. The Royal Navy, under Admiral Cunningham, had made a very successful attack on the Italian fleet at Taranto. British and Commonwealth forces had eliminated the Italians from the Horn of Africa by November 1941.
On the other hand, British and French forces had been evacuated from Dunkirk in June 1940 and France was defeated. Norway, Denmark, Holland, Belgium were all occupied. While the Battle of Britain was being fought, Hitler planned Operation Sealion, the invasion of Britain. Rommel attacked British and Commonwealth forces in the Western desert and besieged them in Tobruk. HMS Hood was sunk by the KM Bismarck which was itself later sunk by units of the Home Fleet, commanded by Admiral Tovey, and Force H from Gibraltar. German forces conquered Yugoslavia, Greece, the Aegean islands and Crete. Malta was under repeated attack. German U-Boats sank 166 ships (472,179 tons) in 1939, 564 (2,391,854 tons) in 1940, 500 (2,210,036 tons) in 1941 and 1,322 more in 1942, although Captain Frederick Walker was establishing himself as the most successful anti-submarine convoy commander of all time.
It was not until June 21st 1941 that Britain gained an ally, the Soviet Union, when Hitler launched Operation Barbarossa, the invasion of Russia with largest invasion force in the history of warfare and which reached the outskirts of Moscow in that winter. On December 7th 1941, the United Kingdom acquired another formidable foe but added a powerful ally, the United States, when Japan simultaneously attacked Malaya, Singapore, Hong Kong and Pearl Harbour.
It was in this grim, ominous scenario that the Government began planning the future NHS. Someone, somewhere had absolute optimism in our future!
Terms of Reference
The terms of reference of the surveys were:
- To gather information about the hospital facilities which were available but which had never before been collected
- To assess the adequacy of these facilities
- To provide expert advice on how these facilities could be best co-ordinated and expanded
The surveyors were all independent, with past or present experience of hospital work, either in clinical or administrative capacities. They were appointed by the Ministry of Health (three areas) or the Nuffield Provincial Hospitals Trust on behalf of the Minister (seven areas). It is noteworthy that one team member was the young George Godber, (Sheffield team) destined to become the best Chief Medical Officer the NHS ever had.
Teams were appointed to cover the following areas:
- London and surrounding areas,
- Berks, Bucks and Oxford,
- Eastern area,
- South Western area ,
- South Wales and Monmouthshire,
- Sheffield and East Midlands area,
- West Midlands area,
- Yorkshire area,
- North Western area,
- North Eastern area.
In the 1940s most large towns had two main types of general hospital: the voluntary, financed by donations and fund raising activities but running into increasing economic difficulties, and municipal funded by government and local authorities but also with some financial problems. Outside the large conurbations were local ‘cottage’ hospitals, which provided simpler forms of treatment. In addition, there were specialist hospitals for mental diseases, infectious diseases, orthopaedics, ENT, children’s units and others. Hospital sizes varied from very large with over a thousand beds to those with 50 or fewer. Less than half the hospitals in England and Wales (other than mental and convalescent homes) and less than one third of the total beds were under voluntary control. Most of the remainder were local authority controlled.
The municipal hospital might be either acute or chronic. The staffs of the former were managed by a medical superintendent, whose duties were mainly administrative. The resident medical staffs usually had considerable experience and were supported by a number of recently qualified junior doctors. However, the majority of local authority general hospitals were institutions for the chronic sick and varied in size from those with hundreds of beds to the very small, which lacked resident medical staff. They were overcrowded, tended to lack the skills or facilities provided by the teaching hospitals but the general standard of ward cleanliness was compatible with that found in the acute general hospitals. Crucially, when chronic sick patients were admitted to a bed they had a ‘bed for life’.
The teams’ general comments
The style and approach of the teams varied. Some were administrative, while others were both descriptive and prescriptive. Most considered the number of beds, the number of consultants and accessibility of health services.
Acute general, maternity, tuberculosis, infectious diseases and chronic sick services required approximately 98,000 extra beds. This lack of capacity led to long waiting lists and delays in admission. Bed shortages in local authority hospitals, which had to admit patients refused by the voluntary hospitals, were worst, and were overcrowded and understaffed. However, it was thought that if more beds became available, it might attract previously unmet demand for hospital care and again lead to bed shortages. Centrally based hospitals in towns often lacked space for expansion and could not respond even if the demand for more beds was agreed. Many older hospitals were gloomy, depressing and inappropriate for nursing purposes, which did little for patient morale.
Consultants working in voluntary hospitals, were not distributed satisfactorily, which resulted from their method of payment. They were not salaried, had to rely on private practice for their income and often had duties in several different hospitals, which due to travelling, diluted their available clinical time. This system of payment could result in a patient in a general ward having to wait for a consultant opinion until a private patient also required consultant advice. Junior staffs in these voluntary hospitals were paid and competition for these posts was always stiff.
The payment arrangements were different in municipal hospitals. In the acute hospitals, doctors were whole time salaried staff supported by part time visiting specialists, who did not control the beds and who therefore had little vested interest in the development of that hospital.. This increased separation of the work of the voluntary and municipal hospitals. The custom of paying low salaries to whole time clinicians and more to the medical administrator exacerbated the situation and drove doctors to seek these posts rather than the clinical ones.
The teams noted poor co-ordination between hospitals as each struggled for self-sufficiency. Voluntary hospitals tended to have an independent spirit, their own initiatives and ways of inspiring local loyalty, and might compete with a neighbouring hospital across an adjacent county boundary. Co-operation between voluntary and municipal hospitals tend to weaken when the former tried to dump on the latter the patients they no longer wanted or felt unable to treat. Local authority boundaries led to uneconomic development and barriers to admission.
Unfortunately, many general hospitals did not have a well-developed almoners’ service, which formed an important link between the hospital patient and the local social services and thus played an important role in patients’ recovery. The surveyors considered that almoners should not be responsible for assessing the patient’s contributions to the hospital for the cost of their maintenance as often happened. Such a function could reduce trust between patient and officials.
The Chronic Sick
The teams reserved their fiercest and most damning criticisms for the provision of care for the chronic sick. ‘The reproach of the masses of undiagnosed and untreated cases of chronic type, which littered the Public Assistance Institutions, must be resolved.’ (Eastern Region). ‘It was a sad sight to see old people sitting in cheerless surroundings waiting for death to set them free’. (Berks Region) Their care was so poor that it required a complete and revolutionary change if they were to be properly cared for. The organization of the professional work and the accommodation all needed reform, although the attention and care given to the patients was as good as the environment and circumstances allowed. Regrettably, the quality of the accommodation was likely to take many years to correct but should not be an excuse for failing to sort out organisational obstacles.
Definition. Assessors thought that the term ‘chronic sick’ should be eliminated because a patient so labelled would be regarded as ‘incurable’ and not requiring the same amount of medical attention. Several teams attempted to define the ‘chronic sick’ and agreed it had shades of meanings. In its broadest sense, it included all those who were not acutely sick. The definitions suggested that the ‘chronic sick’ could be classified into three groups:
- Those who received proper medical care in the early stages of their illness and could be returned to normal living,
- Those suffering from recurrent illnesses, who were not curable, but given appropriate treatment could be returned to their homes,
- Those with irremediable illness who required accommodation in facilities appropriate to their needs but who should be subject to periodic review.
Generally, assessors considered acute beds for the elderly should be on the main hospital site under expert medical supervision where they would be a useful addition to the Schools of Nursing and Medicine. Teaching hospitals might also benefit from having a few such beds. Such arrangements would improve the education of the young nurse and doctor, who would learn to intervene at an earlier stage in an illness thus preventing chronicity. Furthermore, the mass of clinical material would provide considerable scope for research. The Health Authority should be responsible for these patients wherever they were admitted. There was general agreement that children, mothers, the mentally infirm should not be in chronic sick hospitals.
The basic principle should be to restore every patient to the maximum of their useful activity and not confine them unnecessarily in a hospital bed. The first essential was that every patient should be admitted to an acute ward, be thoroughly examined and treated to achieve maximum activity. Only if treatment was unsuccessful or was clearly useless, should he/she be regarded as chronically sick and even then the patient should be periodically reviewed. Teams noted that many patients in chronic sick beds could, with appropriate treatment, be returned to the community. Consequently, it was desirable that the accommodation for the chronic sick should be in close proximity to the acute general hospital, so that the medical and nursing staff should be common and medical supervision should be close and continuous. The needs of the young chronic sick were different from the older patient and therefore should be in their own separate accommodation. If these suggestions were implemented then bed requirements might well be reduced.
General practitioners should assist in the care of the chronic sick, make frequent reviews of the patients’ physical condition and their visits should be supplemented by regular visits by a specialist physician and an orthopaedic surgeon. Visits from local voluntary organisations could assist in maintaining social care. The mass of clinical material found amongst chronic sick patients could be valuable for teaching and clinical research, which could improve knowledge of the diseases of ageing and their treatment.
Almost without exception, the accommodation for the chronic sick was in Public Assistance Hospitals, often dating from the 1900s. Some, built in the 1830s, were originally penitentiaries, and certainly not intended as acute general hospitals. The Wales report stated categorically that the worst and oldest buildings were set aside for the chronic sick. Not surprisingly, some hospitals had a forbidding barrack like appearance, which exuded the unmistakable aura of ‘the workhouse’. Many were death traps in cases of fire. They seldom had an outpatient department and were ill equipped with surgical theatres or X-ray equipment although some expenditure in the 1930s had improved matters. In most instances the wards did not provide either the physical or mental amenities found in even the most ordinary, well conducted domestic dwelling. The patients were in crowded wards, where beds were placed in rows closely opposed to each other and where windows were placed so high that the patients could only see the sky. Often the sanitary arrangements were completely out of date, insufficient in numbers and difficult to access. The stairs made it difficult for all but the most able to access the outside environment. Diversional activities were limited to the wireless.
In future, wards for the chronic sick should be single storey units, which were well lit, airy and with windows providing an easy pleasant outlook and access to the outside, which would enable patients to enjoy their life. The regime should be as little institutional and as homely as possible. Active elderly patients should be in separate accommodation from the chronic sick patients who required medical/nursing attention. All units should have easy access to the acute general hospital.
Generally, the chronic sick wards were seriously and constantly understaffed with little to attract good quality nurses. The ratio of trained nursing staff to patients was as bad as one to 60 and much of their work was routine. The general impression was that of small numbers of overworked nurses struggling with primitive insufficient equipment, which could degenerate into thankless drudgery. None of this was a credit to the country.
What impact did the surveys have?
Just as the Charles Andrews’ survey of chronic sick hospitals in Cornwall led to specific significant developments, so it would be nice to record that these government inspired surveys culminated in similar identifiable advances in the care of older people. Certainly the Ministry was very concerned that some 70,000 beds were occupied by chronic patients, who considered they were there for life. Unhappily, even with hindsight, it is difficult to point to any particular event relating to the chronic sick, which was a direct result of these surveys. Commentators, in later years, have pointed to the lack of a coordinated plan for the care of older people. The provision of their care was generally disappointing and indeed, in some respects, was worse in the early NHS years compared with the pre-war eras. The reasons for this deplorable response are not too hard to seek: competition for resources and economics.
Competition for resources.
As early as 1942, William Beveridge wrote ‘the nature and extent of the provision to be made for old age is the most important and in some ways the most difficult, of all problems of social security’. He continued ‘It is dangerous to be in any way lavish to old age until adequate provision has been made for all other vital needs such as the prevention of disease and the adequate nutrition of the young’. Later, the Nuffield Foundation also cautioned that the provision of care of the elderly had to take account of the country’s limited wealth, labour and resources. Slum clearance, halted during the war, and major rebuilding of war-damaged properties, were key requirements.
The United Kingdom finished the war bankrupt and in the immediate post-war period went through a series of economic crises. Help came from America in the form of Marshall Aid, which aimed to assist the return of normal economic health in the world and reduce the likelihood of a communist takeover of Western Europe. Between 1948 and 1951, the United Kingdom received $3,297,000: more than any other European country. Churchill described the Marshall plan as ‘the most unselfish act by any great power in history’.
So did the surveys achieve anything? Presumably, their conclusions were considered alongside all the other information given to the NHS planners in the period 1946-1948. Improvements did slowly occur, but the chronic sick and the elderly lack popular appeal. ‘Children have needs but the elderly present problems’. Today, what has changed? Bottom of the pile as usual!
- Beveridge W., Social Insurance and Allied Services. Cmnd 6404. London: HMSO, 1942
- Bevers E.C., Gask Professor G. E., and Parry Professor R.H. Ministry of Health: Hospital Survey - The Hospital Services of Berkshire, Buckinghamshire, and Oxfordshire. London: HMSO. 1945.
- Eason Sir H, Clark R.V., and Harper W.H. Ministry of Health: Hospital Survey - The Hospital Services of the Yorkshire Area. London: HMSO. 1945.
- Gray A.M.H. and Topping A. Ministry of Health: Hospital Survey - The Hospital Services of London and the Surrounding Area. London: HMSO. 1945.
- Hunter J. B., Clark R. V. and Hart E., Ministry of Health: Hospital Surveys - The Hospital Services of the West Midlands Area. London: HMSO, 1945.
- Jones A. T., Nixon Professor J. A. and Picken Professor R. M. F., Welsh Board of Health: Hospital Surveys - The Hospital Services of South Wales and Monmouthshire. London: MSO, 1945.
- Parsons Professor L.G., Fryers S Clayton, and Godber G.E. Ministry of Health - Hospital Survey: The Hospital Services of the Sheffield and East Midlands Area. London: HMSO. 1945.
- Savage Sir W.G., Frankau Sir C., and Gibson Sir B. Ministry of Health: Hospital Survey - The Hospital Services of the Eastern Area. London: HMSO. 1945.
- Zachary Cope V, Gill W.J., Griffiths Arthur, Kelly G. C. Ministry of Health: Hospital Survey of the South-Western Region. London, HMSO 1945
- Lett Sir Hugh, Quine A. E. Ministry of Health: Hospital Survey of the North-Eastern Area. London, HMSO 1946
- Nuffield Provincial Hospitals Trust. The Hospital Surveys: The Domesday Book of the Hospital Services. University Press, Oxford, 1946
- Nuffield Foundation. Old People. Oxford: Oxford University Press, 1947