1065 1914-18 war. In 1928 nearly 7000 hospitals were in operation, but in the ensuing ten years over 600 closed their doors ; the reason was that these were not well planned or spaced, and thus could not survive the depression. Just before the second war factories were dispersed ; and this revealed that hospitals were not properly distributed and that the hospital services were not. suitably. coordinated. Thus in 1943 the American Hospital Association decided to seek the federal govern- ment’s help in building and siting hospitals ; and the government set up a commission on hospital care, which reported in 1946. The association then decided to ask Congress for help, and the federal Public Health Service, working with hospitals and doctors, formulated a national programme, which was incorporated in the Hospital Construction Act, passed in the same year. During the next twelve months each State surveyed its’ needs and proposed plans for approval by the federal government ; and in the subsequent year the govern- ment grant under the Act-$75 million per annum- was distributed for the first time. This sum was insuffi- cient, so a priority list was formed on the basis of the population and wealth of each State. Already 400 hospitals were under construction, while a further 400 were planned. The programme was to continue for five years, but even then only 15% of the needs exposed by the reports from the States would have been covered. The State plans called for a regional arrangement with a so-called " base area " (consisting of a teaching hospital) at the centre, and with intermediate and rural areas- towards the periphery. It was hoped that in a few years these three areas would be administratively linked, though this would depend on voluntary agreement ; the States and the universities recognised that only thus could good hospital services be afforded to each rural area. In France, Dr. BRIDGMAN explained, hospitals are being surveyed and classified, with the purpose of establishing a regional scheme ; at the centre of each region will be a teaching hospital (which will also deal with the rare specialties), and towards the periphery the general hospitals and the local hospitals, which will have to be modernised and will serve as a link with the preventive services. A representative from Switzerland declared that his country had been divided into health districts since 1292 ; for hospitals were the concern of the individual cantons. The trouble was that some cantons (mostly the large ones) were rich, while- others were poor ; and thus the service was not uniform. A non-governmental survey was now being made ; and it was hoped that in 3-4 years there might be a nation-wide plan with which the cantons would be willing to comply. Other contributors told how in the Republic of Ireland a regional scheme is being developed around the three universities ; in Sweden there are 30 hospital districts ; in Norway hospitals are to be organised in some 20 regions, while in Denmark they are already grouped in 18 regions ; in Italy the new constitution lays down hospital regions ; and Portugal has legislation for regional and local hospitals. Finally, Dr. MAITLAND reminded the conference that while the regional planning of hospitals was easy, the synthesis of hospital and other medical services was not so easy. OTIIER MEETINGS A discussion on the Vocation, Aim, and Task of Hospitals was opened by Dr. E. HOELFN (Holland). Papers were presented on the Influence of Economic and Social Changes on Hospital Administration by Prof. F. PULCHER (Italy), on the Training of Hospital Administrators by Mr. GEORGE BUGBEE (U.S.A.) (read in the author’s absence by Captain J. E. STONE, the hon. secretary) ; and on Personnel Manage- ment in Relation to Hospital Service by Mr. J. N. ArPELBE. The proceedings are to be published. At the general assembly, on the last day of the con- ference, it was announced that the executive committee proposes to establish in London an international bureau of hospital information. Three study committees are to be set up-on hospital design and construction, on administration, and on patient care. The federation is also to start its own bulletin as soon as funds suffice. The committee had accepted an invitation to hold the next conference, in 1951, in Atlantic City ; but members pointed out that, while American hospitality would minimise the cost of stay in the U.S.A., the expense of crossing the ocean might prevent many Europeans from attending. The committee agreed to reconsider - the position. * The theme of the next congress is to be the regional organisation of medical care. HEALTH SERVICE ESTIMATES SELECT COMbIITTEE’S REPORT THE administration of the National Health Services has been reviewed by the Select Committee on Estimates, whose report was published last week as a blue-book.! The committee suggests that, while it is too early to judge whether the services as a whole are being managed economically, there is scope for review of their detailed working and of the remuneration and conditions of service of those engaged in providing them. There is also need for public recognition that abuse of the services may threaten their maintenance and further expansion. The administrative costs and staff of executive councils appear to the committee to be reasonable ; but the system of admitting doctors to a council’s list should, it says, be examined with a view to making it simpler and more speedy. The earnings of some dentists under the scheme are found to be excessive ; and the Health Departments are advised to examine the schedule of cases which dentists have to submit for prior approval to the Dental Estimates Board, with a view to reducing their number. Greater care, the committee claims, should have been taken in framing the original estimate for the supplementary ophthalmic services in 1948-49. To avoid abuse of the pharmaceutical services, the Health Departments should make regulations for the purpose of preventing excessive or wasteful prescriptions ; and the schedules of medicines and appliances available under the health services should be reviewed from time to time. As regards the hospital service, the system of adminis- tration should be examined as soon as enough working - experience is accumulated ; in England and Wales a uniform system of costing should be devised, and the question of setting up an internal efficiency audit, similar to that carried out by Scottish regional boards, should be examined. The committee points out that the efficiency of the service cannot be gauged while it is still in its infancy ; but " it was gratifying to find from the evidence that, on the whole, the scheme was settling down with surprisingly little friction." THE COST If the estimates prove correct, the cost to the taxpayer of the National Health Services in 1948-49 (including the cost of headquarter administration) will be about jE261 million, after deduction of the £40,700,000 which is to -come from National Insurance contributions. (The total expenditure in connexion with the services is estimated at over £352 million.) " There is a wide- 1. Seventh Report from the Select Committee on Estimates Session 1948-49. The Administration of the National Health Services. H.M. Stationery Office. 4s.
Transcript
1065
1914-18 war. In 1928 nearly 7000 hospitals were inoperation, but in the ensuing ten years over 600 closedtheir doors ; the reason was that these were not well
planned or spaced, and thus could not survive the
depression. Just before the second war factories were dispersed ;
and this revealed that hospitals were not properlydistributed and that the hospital services were not.
suitably. coordinated. Thus in 1943 the American
Hospital Association decided to seek the federal govern-ment’s help in building and siting hospitals ; and the
government set up a commission on hospital care, whichreported in 1946. The association then decided to ask
Congress for help, and the federal Public Health Service,working with hospitals and doctors, formulated a nationalprogramme, which was incorporated in the HospitalConstruction Act, passed in the same year.During the next twelve months each State surveyed its’
needs and proposed plans for approval by the federalgovernment ; and in the subsequent year the govern-ment grant under the Act-$75 million per annum-was distributed for the first time. This sum was insuffi-cient, so a priority list was formed on the basis of thepopulation and wealth of each State. Already 400
hospitals were under construction, while a further 400were planned. The programme was to continue for five
years, but even then only 15% of the needs exposed bythe reports from the States would have been covered.The State plans called for a regional arrangement with
a so-called " base area " (consisting of a teaching hospital)at the centre, and with intermediate and rural areas-towards the periphery. It was hoped that in a few
years these three areas would be administratively linked,though this would depend on voluntary agreement ; theStates and the universities recognised that only thuscould good hospital services be afforded to each ruralarea.
In France, Dr. BRIDGMAN explained, hospitals are
being surveyed and classified, with the purpose of
establishing a regional scheme ; at the centre of each
region will be a teaching hospital (which will also dealwith the rare specialties), and towards the periphery thegeneral hospitals and the local hospitals, which will haveto be modernised and will serve as a link with thepreventive services.A representative from Switzerland declared that his
country had been divided into health districts since1292 ; for hospitals were the concern of the individualcantons. The trouble was that some cantons (mostlythe large ones) were rich, while- others were poor ; andthus the service was not uniform. A non-governmentalsurvey was now being made ; and it was hoped that in3-4 years there might be a nation-wide plan with whichthe cantons would be willing to comply.
Other contributors told how in the Republic of Irelanda regional scheme is being developed around the threeuniversities ; in Sweden there are 30 hospital districts ;in Norway hospitals are to be organised in some 20regions, while in Denmark they are already grouped in18 regions ; in Italy the new constitution lays downhospital regions ; and Portugal has legislation for
regional and local hospitals.Finally, Dr. MAITLAND reminded the conference that
while the regional planning of hospitals was easy, thesynthesis of hospital and other medical services was notso easy.
OTIIER MEETINGS
A discussion on the Vocation, Aim, and Task of Hospitalswas opened by Dr. E. HOELFN (Holland). Papers werepresented on the Influence of Economic and Social Changeson Hospital Administration by Prof. F. PULCHER (Italy), onthe Training of Hospital Administrators by Mr. GEORGEBUGBEE (U.S.A.) (read in the author’s absence by CaptainJ. E. STONE, the hon. secretary) ; and on Personnel Manage-
ment in Relation to Hospital Service by Mr. J. N. ArPELBE.The proceedings are to be published.At the general assembly, on the last day of the con-
ference, it was announced that the executive committeeproposes to establish in London an international bureauof hospital information. Three study committees are tobe set up-on hospital design and construction, on
administration, and on patient care. The federation isalso to start its own bulletin as soon as funds suffice.The committee had accepted an invitation to hold thenext conference, in 1951, in Atlantic City ; but memberspointed out that, while American hospitality wouldminimise the cost of stay in the U.S.A., the expense ofcrossing the ocean might prevent many Europeans fromattending. The committee agreed to reconsider - the
position. * The theme of the next congress is to be the
regional organisation of medical care.
HEALTH SERVICE ESTIMATES
SELECT COMbIITTEE’S REPORT
THE administration of the National Health Serviceshas been reviewed by the Select Committee on Estimates,whose report was published last week as a blue-book.!The committee suggests that, while it is too early tojudge whether the services as a whole are being managedeconomically, there is scope for review of their detailedworking and of the remuneration and conditions ofservice of those engaged in providing them. There isalso need for public recognition that abuse of the servicesmay threaten their maintenance and further expansion.The administrative costs and staff of executive
councils appear to the committee to be reasonable ;but the system of admitting doctors to a council’s listshould, it says, be examined with a view to making itsimpler and more speedy.The earnings of some dentists under the scheme are
found to be excessive ; and the Health Departmentsare advised to examine the schedule of cases whichdentists have to submit for prior approval to the DentalEstimates Board, with a view to reducing their number.
Greater care, the committee claims, should havebeen taken in framing the original estimate for the
supplementary ophthalmic services in 1948-49. Toavoid abuse of the pharmaceutical services, the HealthDepartments should make regulations for the purposeof preventing excessive or wasteful prescriptions ; andthe schedules of medicines and appliances availableunder the health services should be reviewed from timeto time.As regards the hospital service, the system of adminis-
tration should be examined as soon as enough working- experience is accumulated ; in England and Wales a
uniform system of costing should be devised, and thequestion of setting up an internal efficiency audit,similar to that carried out by Scottish regional boards,should be examined.The committee points out that the efficiency of the
service cannot be gauged while it is still in its infancy ;but " it was gratifying to find from the evidence that,on the whole, the scheme was settling down with
surprisingly little friction."
THE COST
If the estimates prove correct, the cost to the taxpayerof the National Health Services in 1948-49 (includingthe cost of headquarter administration) will be aboutjE261 million, after deduction of the £40,700,000 whichis to -come from National Insurance contributions.(The total expenditure in connexion with the servicesis estimated at over £352 million.) " There is a wide-
1. Seventh Report from the Select Committee on EstimatesSession 1948-49. The Administration of the National HealthServices. H.M. Stationery Office. 4s.
1066
spread belief that the whole of the cost of the NationalHealth Services is provided by means of the NationalInsurance contributions," whereas actually appropria-tions for this purpose amount to the equivalent of
1d. a week from each employer, 10d. a week fromeach self-employed and non-employed person, 8d. or6d. respectively from each male or female employeeover 18 years of age, and 4d. from each boy or girlemployee under that age ; and these contributionswill cover only about one-ninth of the whole cost.
GENERAL MEDICAL SERVICES
. The estimated expenditure by executive councils onadministration is about 2% of their total expenditure(though in reckoning the complete cost of administrationDepartmental expenses must be added). As to the staffingof executive councils, " the danger, at present, seemsto lie in shortage of suitable staff for the job ratherthan in overstaffing, and the establishments did notseem to be excessive for the volume of work,"
Patients complain of delay in obtaining treatmentand of queues in doctors’ waiting-rooms, and this isdue partly to the uneven distribution of practitioners ;in Scotland the proportion of doctors to patients variesin different areas between 1 : 1018 and 1 : 2646. The
system of filling vacancies on the lists of executivecouncils was described by a witness as cumbrous andlikely to deter a doctor anxious to join the scheme ;and an instance was quoted of a death vacancy beingunfilled after four months.
GENERAL DENTAL SERVICES
The revised estimate for dental services in Englandin 1948-49 was 2½ times the original figure ; " some ofthe assumptions made by the Departments in framingtheir Estimates were, to say the least, optimistic."The committee heard evidence of some of the difficultiescaused by the system of contract between dentistsand executive councils.
" Instances have been reported of dentists refusing toextract the teeth of patients suffering acute pain, unless thepatient offered to pay ; and as dentists are paid by piecework,with no limit to the number of hours that can be worked,exceptionally high earnings can be made... in Renfrewshire,for example, there was in November one dentist receivingbetween £1300 and E1400 gross a month, and at least twoothers, single dentists without assistants, receiving over
E800 a month.... Your Committee appreciate that dentistsincur higher expenses in the course of their practice ; never-
theless, it may be noted that the General Dental Services,involving some 9000 dentists, are estimated to cost £30,904,000in 1949-50, as compared with £45,800,000 for the GeneralMedical Services involving over 19,000 doctors."
In support of the argument for reducing the numberof cases where prior approval by the Dental EstimatesBoard is required, the report cites estimates for theextraction of a number of teeth for people who requiredentures and who are not below a certain age, where
approval is given without further inquiry.
SUPPLEMENTARY OPHTHALMIC SERVICES
In 1948-49 the revised estimate for the supplementaryophthalmic services was £14,970,000—more than sixtimes the original estimate of £2,330,000. The difference,says the report, was due to failure to take full accountof rate of demand and of the number of people to whomthe service was to be available ; moreover, the cost of
providing spectacles was underestimated. Whereas thecost was originally assumed to be the same as underNational Health Insurance-namely 40-45s.-it turnedout to be 65s. 6d., the fees for sight-testing having beendoubled. The committee " have no conclusive evidencethat the safeguards are adequate to prevent peopleobtaining more spectacles than they are entitled tounder the scheme." Furthermore if unpleasant reper-
cussions are to be avoided remuneration in the ophthalmic,as also in the dental, service should be settled as earlyas possible.
PHARMACEUTICAL SERVICES
That the number of prescriptions per head is higherunder the National Health Services than under NationalHealth Insurance, the committee attributes partly tothe publicity which the new service received, and partlyto patients taking the fullest advantage of the oppor-tunity to obtain without charge such things as bandagesand aspirin. Evidence suggested that the pricing bureauxhave hitherto erred on the side of leniency.With regard to the family-practitioner services in
general, the committee " have found no obvious majordefects in the administration."
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HOSPITAL SERVICES
The committee speaks with approval of the practicein Scotland whereby the regional hospital boards employan internal audit staff which not only examines expendi-ture to see that it has been legally incurred but alsodeals with questions of administration and assists boardsof management in compiling statistics of costing ; theseare prepared in a form which gives the average costper bed for different types of hospital. In Englandand Wales some regional boards and at least one teachinghospital are keeping statistics of cost on their owninitiative, but so far-no uniform system has been evolved.The original hospital estimates for 1948-49 fell short
of the eventual need by some 10-15%, for a number ofreasons, among which were the increased wages forstaffs, and expenditure on maintenance of buildingsand plant which it had not been possible to undertakeduring the war.
" It was also suggested that local authorities, on discoveringthat they were not going to be responsible for running thehospitals under the National Health Services, had out downexpenditure on items of major importance in 1946 and that,because of this, expenditure in 1946 had proved to be a
false guide in framing the original Estimate for 1948-49."The cuts imposed this year, with a view-to bringing
down the expenditure by boards to the same level asin the year ended March 31, amount on average to 8%of the estimates submitted in the case of teaching hos-pitals in England and Wales and 5% in the case of
non-teaching hospitals." Where a comprehensive cut of this kind has to be made,’’
the committee concludes, ’" the burden inevitably falls withuneven degrees of hardship. So far as capital expenditureis concerned, it was generally agreed by the witnesses examinedthat the reduced expenditure would probably be enoughfor the most urgent work to be carried out, but varyingaccounts were given of how the other reductions in expendi-ture would affect hospitals. One witness from a ScottishRegional Board stated that he did not think the cuts wouldembarrass the Board seriously in carrying on existing,services.Another witness, however, claimed that the expenditureallowed in his district had been reduced so drastically thatit would not now be possible to use wards for which staffwere available. It seems clear that the Ministry of Healthwill be approached by some of the Boards with a statementthat the cuts in expenditure cannot be made without seriouslyendangering the standards of service provided. For, apartfrom expenditure which has been reduced’ as a matter of
policy, the original estimates submitted by the hospitalsfor 1949-50 did not allow any money to cover unforseen
expenditure ; this was in accordance with the express instruc-tions of the Departments. Moreover, it must be rememberedthat there are fairly narrow limits to the expenditure whichcan be reduced by the actions of Hospital Boards. Salariesand wages form over 50 per cent. of the total cost of runninga hospital and are settled according to scales agreed centrally.The expenditure which least directly affects the welfare ofpatients and in which a cut would most naturally be sought,namely administration, forms only 2 per cent. of the totalcost."
