maximum efficiency is secured by the poor-law system of
medical relief. The remedy is very simple and easy of application.
Every voluntary hospital, while admitting all accidents and
urgent cases needing immediate attention, should institute a
system whereby each applicant would be asked to prove that
he or she was a fit object of charity. The only real attempt
at reform, up to 1909, was the appointment by many of the larger
hospitals of almoners to ascertain whether certain selected
patients were in a position to pay or not. By putting the burden
of proof of eligibility to receive free medical relief upon the
patients and their friends, all abuse of every kind must speedily
cease. There would be no hardship entailed upon the patients by
such a system, as experience has proved, but, to make it effective,
the system of providing for in- and out-patients in Great Britain
requires radical change, for, in existing circumstance, if a
voluntary hospital attempted to enforce this simple method, it
would be met with the difficulty that, where it was found that
a patient or his friends could pay at any rate something, no
department connected with British hospitals existed—as is the
case in regard to hospitals in the United States—enabling such
in-patients to be transferred to accommodation provided in
paying wards. In the same way, directly the out-patients
were dealt with under such a system, it would be made apparent,
where a case could be properly treated, under the poor law,
that no plan of co-operation to secure this was organized under
existing conditions. If the patient, being of a better class, were
suffering from a minor ailment, and could be properly dealt with
at a provident dispensary, the fees of which he could easily
pay, the same absence of co-operation must make it practically
impossible readily to enforce the system. When, again, an out-patient
of the better class was entitled, from the severity of his
ailment, to receive the advantages of a consultation by the
medical staff, no method existed whereby this aid could be
rendered to him, and his transfer afterwards to the care of a
medical practitioner attached to some provident dispensary,
or resident near the patient’s home, could be properly carried
out. It follows that adequate reform required that methods
should be adopted with a view to some part or all the cost of
treatment being provided by the patient or his friends through
an entire reorganization of the system of medical relief not only
at the voluntary hospitals, but under the poor-law system. The
reforms required in regard to voluntary hospitals are that every
large hospital shall have connected with the in-patient department,
in separate buildings, but under the administration of
the managers, pay wards for the reception of those patients who
are able to pay some part or all of the cost of treatment; that,
as regards out-patients, the existing out-patient department
should be abolished; that in substitution for it each hospital
should have a casualty department and a department for
consultation. In the casualty department every applicant
should be seen once, and be there disposed of by being handed on
to the consultation department; if his case was sufficiently
important, he should then be transferred to some provident
or poor-law dispensary, or be referred to a private medical
attendant. It would no doubt take time to overcome the incidental
difficulties which would necessarily arise in effecting
so radical a reform as is here contemplated, but if all voluntary
hospitals adopted the same system, and were to be brought into
active co-operation with provident dispensaries and poor-law
dispensaries and private medical practitioners, the new system
might be successfully introduced and made effective within
twelve months, and probably within six months, from the date
of its commencement. This opinion is based upon the assumption
that the provident dispensaries would be standardized,
and that every one of them would be brought up to a state of the
highest efficiency. In the town of Northampton the Royal
Victoria Dispensary has been worked with the maximum of
success, so far as the patients and the medical practitioners are
concerned. In London and in other large towns like Manchester
and elsewhere the provident dispensary has not succeeded as
it has done in Northampton, because so many members of the
medical profession are not alive to the importance of making
it their first business to provide that every patient connected
with the provident dispensary who attends at the surgery of a
private medical practitioner shall receive at least equal attention
and accommodation to that afforded to every other private
patient, whatever the fee he may pay. In the same way, poor-law
dispensaries must be radically reformed. Everything which
tends to excite a feeling of shame on the part of the patient
attending the poor-law dispensary, such as the printing of the
word “pauper” at the beginning of the space on which the
patient’s name is entered, must be abolished, and the class of
medical service and all the arrangements for the treatment
of the patients, however poor, at the poor-law dispensary,
must be made at least as efficient as those provided by voluntary
hospitals. There undoubtedly is considerable overlapping
between the voluntary hospitals and the poor law in Great
Britain. The Royal Commission on the Poor Laws and Relief
of Distress (1909) deals with this point with a view to set up a
standard of medical relief to be granted by each class and type
of hospitals, provides for adequate co-operation between all
classes of institutions; and these reforms may be commended.
It is too often forgotten that the function of the poor law is the
relief of destitution, while it should be the object and duty of
each voluntary hospital and indeed of all hospitals other than
poor-law institutions to apply their resources entirely to the
prevention of destitution, by stepping in to grant free medical
relief to the provident and thrifty when, through no fault of
their own, they meet with an accident or are overtaken by
disease. An adequate system of co-operation would preserve
the privilege of the voluntary hospitals, which save such patients
from the necessity of requiring the relief which it is the object
of the poor law to supply.
We have dealt with the relative advantages and disadvantages of rate-supported hospitals and voluntary hospitals. We should regard the establishment of a complete state-provided or rate-provided system of gratuitous medical relief, either for indoor patients or for out-door patients, or for both, as a grave evil. Such a system must eventually lead to the extinction of voluntary hospitals. If this disaster ever happens, it must result in the gravest evils, for it could not fail to injure the morale of all classes and tend to harden unnecessarily the relations between the rich and poor, who, under the voluntary system, have come to share each other’s sufferings and to be animated by respect and confidence towards each other.
Hospital Construction. Locality and Site.—Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is now proved to demonstration that this is not the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to population, it would certainly be better to place hospitals as much in the outskirts as is consistent with considerations of usefulness and convenience. In short, the best site would be open fields; but if that be impracticable, a large space, “a sanitary zone” as it is called by Tollet, should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. In the selection of a site various factors must be taken into consideration. If the hospital is to be used as the clinical school of a university or medical college, then the most suitable ground available within easy reach of the university or college must be secured. If, on the other hand, the hospital is not to be used as a teaching school, a site more in the country should be favoured. In any case ample ground must be purchased to permit of the wards receiving the maximum of sunlight, an abundant supply of fresh air, and leave room for possible future extensions. The site should be self-contained; it should be in such a position as to prevent the hospital being shadowed by other buildings in the neighbourhood, and, unless the site is alongside a public park, it should be entirely surrounded by streets of from 40 to 60 ft. in width. It is also necessary to secure that adequate water mains serve the site, and that the system of sewers be ample for all sewage purposes.
The difference between the expense of purchase of land in a town and in the environs is generally considerable, and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas’s in London, the Hôtel-Dieu in Paris
