the material required, under present systems, for the efficient
training of students and nurses, would be removed by the
erection of the Hospital City, which, he foresees, must ultimately
be recognized by intelligent communities throughout the
civilized world. Why should we not have, on a carefully selected
site well away from the contaminations of the town, and
adequately provided with every requisite demanded from the
site of the most perfect modern hospital which the mind of
man can conceive, a “Hospital City”? Here would be concentrated
all the means for relieving and treating every form
of disease to the abiding comfort of all responsible for their
adequacy and success. At the present time all the traffic and all
the citizens give way to fire engines and the ambulance in the
public streets. Necessarily the means of transit to and from
the “Hospital City,” and its rapidity, would be the most perfect
in the world. So the members of the medical staff, the friends
of the patients, and all who had business in the “Hospital
City,” would find it easier and less exacting in time and energy
to be attached to one of the hospitals located therein than to
one situated in the centre of a big population in a crowded town.
To meet the urgent and accident cases a few receiving houses,
or outpost relief stations, with a couple of wards, would be
situated in various quarters of the working city, where patients
could be temporarily treated, and whence they could be removed
to the “Hospital City” by an efficient motor ambulance service.
The writer can see such a “Hospital City” established, can
realize the comfort it will prove in practice to the medical profession,
to the patients’ friends, to those who have to manage
the hospitals and train the medical and nursing students, and
indeed to all who may go there as well as to the whole community.
The initial cost of hospital buildings should be reduced at
once to a quarter or less of the present outlay. They could
then be built of the cheapest but most suitable material, which
would have many advantages, whilst the actual money forthcoming
from the realization and sale of the existing hospital sites
in many cities would, in all probability, produce a sum which in
the whole might prove adequate, or nearly adequate, or even in
some cases more than adequate, to defray the entire cost of
building the “Hospital City” and of equipping it too. The
cost of administration and working must be everywhere reduced
to a minimum. The hygienic completeness of the whole city,
its buildings and appliances, must expedite recovery to the
maximum extent. In all probability the removal of the sick
from contact with the healthy would tend in practice so to
increase the healthiness of the town population, i.e. of the
workers of the city proper, as to free them from some of the
most burdensome trials which now cripple their resources and
diminish materially the happiness of their lives. Probably
the United States (where a city has sometimes sprung up in
twelve months) may be the home where this idea may first
find its realization in accomplished fact. The writer may
never live to see such a city in actual working or in its entirety,
but he makes bold to believe its adoption will one day solve
the more difficult of the problems involved in providing adequately
for the sick in crowded communities. He has formulated
the idea because it seems desirable to encourage discussion as
to the best method of checking the growing tendency to make
hospital buildings everywhere too costly. If the idea of the
“Hospital City” commends itself to the profession and the
public, the practice of treating all the hospital accommodation
in each city as a whole will gradually increase and spread,
until most of the present pressing difficulties may disappear
altogether. That is a consummation devoutly to be wished.
The Problem of Hospital Administration.—A study of the hospital problem in various countries, and especially in different portions of the English-speaking world, convinces the writer that, apart from local differences, the features presented are everywhere practically identical. A number of hospitals under independent administration, dependent in whole or in part on voluntary contributions, administered under different regulations originally representing the idiosyncracies of individual managers for the time being, without any standard of efficiency or any system of co-operation, which would bring the whole of the medical establishments of each or all of the great cities of the world under one administration which the combined wisdom and experience of hospital managers as a whole might agree to be the best, must mean in practice a material gain in every way to each and all of the hospitals and their supporters on economical, scientific and other grounds. Such an absence of system throughout the world has everywhere led to overlapping, to the perpetuation of many abuses, to the admission of an increasing number of patients whose social position does not entitle them to claim free medical relief at all, and, often too, to the admission of patients belonging to a humbler grade of society who are already provided for by the rates in institutions which they do not care to enter and who find their way to the wards of hospitals which were established to provide for patients of an entirely different social grade. These evils have continued to grow and increase almost everywhere, despite many and varied attempts to grapple with and remove them. Amongst these attempts we may mention the assembling of hospital conferences, the establishment of special funds and committees, and the holding of inquiries of various kinds in London and other British cities and also in the United States. The most remarkable proof of the impossibility of inducing those responsible to act together and enforce the necessary reforms is afforded by the historical fact that the famous Commission on Hospital Abuse, known as Sir William Fergusson’s Commission, in 1871, after an exhaustive inquiry, made the following recommendations: (1) to improve the administration of poor-law medical relief; (2) to place all free dispensaries under the control of the poor-law authorities; (3) to establish an adequate system of provident dispensaries; (4) to curtail the unrestricted system of gratuitous relief, partly by the selection of cases possessing special clinical interest and partly by the exclusion of those who on social grounds are not entitled to gratuitous medical advice; (5) the payment of the medical staff engaged in both in- and out-patient work, and the payment of fees by patients in the pay wards and in the consultation departments of the voluntary hospitals. Other commissions have since been appointed, have reported, and have disappeared, with the result that nothing practical had been done up to 1910 in the way of reform. Yet it is an undoubted fact that, if the foregoing recommendations of Sir William Fergusson’s Commission had been carried out in their entirety at the time they were made, practically all the abuses from which British hospitals afterwards suffered would have been removed, and the charitable public might have been saved several millions of pounds sterling. It may be well, therefore, briefly to indicate exactly what these changes amount to, and how they can be made effective at any time by those responsible for the working of a hospital.
There is no doubt that all the facts available tend to prove that the voluntary hospitals are used to an increasing extent by persons able to make payment or partial payment for the treatment which they receive. The evidence and statistics demonstrating these facts may be readily gathered from a study of the Report (1909) and Evidence of the Royal Commission on the Poor Laws and Relief of Distress (Lord George Hamilton’s Commission) and in the authorities mentioned at the end of this article. The underlying cause of the abuse was that no means existed whereby persons of moderate income could obtain efficient treatment and hospital care when ill at a rate which they could afford to pay. The system, or want of system, whereby medical relief is granted to practically all applicants by the voluntary hospitals grew up without any combined attempt to organize it efficiently or to check abuses. Such a system rests upon a wrong basis, and the best interests of every class of the population demand its abolition in favour of one which shall afford the maximum of justice (1) to the poor, (2) to those who can afford to pay in part or in whole the cost of their medical treatment and care at a hospital, (3) to the medical profession, (4) to the subscribers and supporters of voluntary hospitals, whose gifts should be strictly applied to the purposes they were intended to serve, and (5) to the ratepayers, who are entitled to a guarantee that the
