Chapter 23: Hospitals for War Victims
(i) Quantity of Hospital Provision
It has already been shown that the amount of accommodation available within the emergency hospital scheme, although it was considered inadequate before and during the early years of the war, never proved a really serious problem. The shortages that did arise were due, not so much to the numbers of casualties of Service patients, but to the claims of the ordinary sick who had been crowded or bombed out of their hospitals. There were periods when it seemed as if there could never be enough beds in certain areas, and questions of quantity arose whenever the war situation appeared particularly menacing. But on the whole, and especially after 1940, quantity was no longer the primary consideration in Government policy. This was reflected in the number of hospitals suspended or withdrawn from the emergency scheme.1
The process of concentration was largely completed by the end of 1943 when 734 hospitals had been withdrawn, 753 suspended2 and 886 retained in the scheme. In 1944, when the scheme was expanded to receive battle casualties from the Continent, the number of active hospitals rose to 1640, but by the end of the year it had fallen back to 879.3
The exclusion of the smaller and less efficient units had comparatively little influence upon the total number of beds available, for the reason that the reductions were offset by the addition of new accommodation to the active hospitals. By May 1941 the number of new beds provided by ‘up-grading’ alone was equal to the number of beds in hospitals withdrawn from the scheme. When it was found, in some instances, that hospitals were still unsatisfactory after improvements had been carried out, the Ministry’s ‘up-grading’ policy became more selective. There was, of course, a limit to the number of hospitals that
could be improved to suit the purposes of the emergency scheme, and early in 1941 it was decided to restrict work to those institutions which had already been partially, but not yet adequately, adapted to the standards set. By then, 110,000 new beds had been added by means of crowing, ‘up-grading’ and the building of hutted annexes. Another 10,000 were provided by equipping suitable buildings in the neighbourhood of hospitals to act as annexes. Accommodation for convalescence in the new Red Cross auxiliary hospitals was, at the same time, raised to over 10,000 beds.
The most valuable of these various devices to increase the quantity of hospital accommodation was the building of hutted annexes.4 This alone added 34,000 first-class beds by the end of 1940. In the following years an acute shortage of labour and materials slowed down considerably the progress of building. As, moreover, the demands for casualty beds had not been nearly as heavy as expected, the original plan of 80,000 beds in hutted annexes was dropped in the summer of 1942, when over 52,000 beds had been added, 8,600 of them in self-contained hutted hospitals.
It was hoped that the Red Cross auxiliary hospitals would fulfil the twofold purpose of freeing beds in casualty hospitals for those who really needed them and of providing emergency medical service patients with suitable accommodation for convalescence. Such facilities had been very inadequate before the war and some pre-war convalescent homes had since been diverted to other purposes. Here, as elsewhere, the war added its own quota of social problems. Here, as elsewhere, the war added its own quote of social problems. Service patients could not be returned to their units until they were fit, and civilians could not be discharged from hospital in a poor state of health when they had no homes to go to and no relatives to nurse them back to health. The original principle of ‘no convalescence for air raid casualties’5 had long been abandoned by the Ministry of Health, while the strain of long working hours and of air raids made it necessary to provide some people with periods of rest under medical supervision to save them from breakdown. The Ministry therefore took the view that the new auxiliary hospitals should ‘provide a general pool of convalescent accommodation’.
The hospitals were established in large country houses placed at the disposal of the Red Cross, sometimes at nominal rents, by the owners. There was no shortage of such offers which, in many instances, only anticipated Government requisitioning, and the conversion of these houses into convalesce hospitals ensured that they
were maintained and kept in repair.6 Frequently the owners remained in residence and took charge of the hospital under Red Cross auspices. Most of the equipment was provided by the Ministry, which also financed necessary adaptations and paid fixed fees for occupied and vacant beds to the Red Cross Society.
Such a policy of indirect control created problems resembling those which arose in the relationship between the Ministry and the voluntary hospitals. In deciding what categories of patients should be admitted, for instance, the Ministry had to take into account the wishes of the owners of the houses. These people tended to prefer the ‘blue-coated soldier’ who was under military discipline to the industrial worker who was not. But the course of the war meant that, for a number of year, Service patients formed only a small proportion of all patients in need of convalescence; the Ministry, therefore, found itself in the awkward position of paying for beds which were urgently needed for a variety of purposes but which it could not use. Sick civilians, in deed of convalescent treatment, were not admitted to the hospitals although the Government was meeting the bill for both occupied and empty beds. Up to June 1941 the Ministry paid for 1,643,000 ‘bed days’ in auxiliary hospitals; only 605,000 of these were ‘occupied bed days’. This waste was thought to be encouraged by the relatively high rate of payment for vacant as compared with occupied beds. After much delay, these rates were revised at the beginning of 1942,7 and agreement was reached over a year later to use some accommodation for evacuated children, civil defence workers, nurses and other groups.8 The Ministry’s convalescence scheme for miners had to be dropped; its scheme for industrial workers met with so little enthusiasm from the owners of the houses that negotiations were only just completed and applications forms printed when all available accommodation had to be reserved for Second Front casualties.
By August 1944 there were over 14,000 beds, seventy-two percent of them occupied, in more than 230 country houses: the original aim of 20,000 beds had long been abandoned.9 Throughout the war, those who were responsible for administering the auxiliary hospitals were anxious to do all they could for Service casualties. In all,
479,648 patients were treated up to 2nd September 1945.10 A substantial proportion of these patients were admitted during 1944–5, for it was only during the last stage of the war that the hospitals fully played the part in the emergency medical service for which they had originally been created. The contribution they made towards helping with the problems of civilian life in wartime was—by contrast with the service given to members of the Armed Forces—very limited. Of the total of 479,648 patients, only 64,699 were civilians.
To this point, the account has told of increasing assets for the emergency medical service. Its losses, temporary and permanent, were on a smaller scale, but where they occurred they resulted in shortages and caused much disturbance. In the evacuation of hospitals were abandoned. In the bombed cities damage to hospitals was severe. It is difficult to assess these losses in terms of beds for the whole of England and Wales. When air attacks ceased in 1941 they were roughly calculated at between 7,000 and 10,000 with an additional 15,000 beds closed on account of danger.11 The London County Council alone estimated its losses of general and special beds at over ten percent as early as mid-December 1940. Few hospitals were put completely out of action, but quite a number were temporarily brought to a standstill and emptied of staff and patients. By the end of May 1941, London County Council hospitals had suffered damage on no less than 450 occasions involving the closing of ten hospitals and the partial closing of several others. During the flying-bomb and rocket attacks London hospitals were more seriously affected by losses of beds through damage than by the influx of casualties, and at the end of 1944 the London County Council reported a wartime loss of over 5,000 beds.12
Fortunately, these hospital losses were more than offset by gains in the country as a whole. Some of the gains were the result of adaptation to the changing needs of circumstances of the war. The quiet years that followed the air raids of 1940–1 were busy years of adjustment and expansion for the hospitals. With the Armed Forces preparing for greater encounters with the enemy, the Allied and Dominion troops pouring into Britain for the assault on the Continent, there were new demands and developments. Service and Ministry of Pensions hospitals, with some 20,000 beds empty early in 1940, increased their resources to over 37,000 beds by the summer of 1941.13
Sixty hutted hospitals with 52,000 beds were built for the American Forces alone, and the emergency medical service transferred 12,000 of its beds in hutted hospitals and 1,300 beds in its permanent hospitals to the Service departments and the Canadian and U.S. military authorities.
All these changes, in combination with the steadily enlarging responsibilities of the emergency medical service, make it virtually impossible to give an accurate picture of the total resources of the service at different stages of the war. Moreover, in such a large and heterogeneous organisation it was not easy to apply uniform methods of accounting. Distinctions between active and reserve, occupied and unoccupied, staff and unstaffed beds offered many opportunities for overlapping and error, and estimates of the so-called ‘discharge beds’ were matters of policy rather than record-keeping.14 Beds which were ‘largely paper beds’15 were included in some and excluded from other estimates. The term ‘available bed’ inevitably had different meaning at different times.
The degree of pressure exercised on various occasions by the War Office on the Ministry of Health was reflected in the interpretation of what constituted an ‘available bed’. In January and again in May 1941, the War Office asked for assurances that sufficiently large reserves of beds in the emergency medical service would be available in the event of enemy invasion. At the earlier date, the Ministry replied that ‘the effective bed reserve for air raid and Service casualties should be put at under 100,000—‘less than two-thirds of the number the War Office estimated it might need.16 In May, the Ministry believed that including approximately 40,000 beds in Scottish hospitals ‘at least 195,000 reasonably staffed beds, and probably 212,000’ could be found, with a further reserve of partly staffed and unstaffed beds to replace bombed hospitals. The chief reason for the difference in the Ministry’s replies was one of interpretation, not of fact, as the hospital position had undergone little change during the intervening period. What had changed was the war situation. In January 1941
shortage was emphasised because civilian needs, aggravated by air attack, by the dangers to health of life in the shelters and by the risks of winter epidemics, were in the foreground. In May the Ministry apologised for its earlier pessimism,17 and the term ‘available bed’ received a much wider interpretation because the invasion season was at hand.
Nevertheless, after its experience during the first two years of war, the Ministry did not again regard the demands of sick civilians as a secondary matter in time of war. In its records of hospital accommodation, the figures of ‘discharge beds’ furnished an interesting barometer to changing opinion. In July 1940 the figure was still estimated at up to 120,000, and it was understood that these beds could be freed within twenty-four hours be sending civilian patients to their own homes. By the following January the number of discharge beds had sunk to 37,800 and even that figure was given with reservations. Soon afterwards a new and wider definition of this class of bed was formulated.18 It now covered all categories of Service and civilian patients, and the Ministry hoped that thirty to forty percent of all first-class beds could be cleared in an emergency by transferring patients to less specialised accommodation, particularly auxiliary hospitals, or by sending them home wherever possible. The results of applying this wider definition after a special appeal to hospitals were disappointing. In May 1941 only 43,000 discharge beds were reported by hospitals, but the Ministry, in its estimate to the War Office, increased the figure to 60,000.
In July 1941, hospital resources were surveyed for the War Cabinet in preparation for possible heavy air assaults in the following winter; they were considered to be ‘sufficient to meet likely eventualities’. Total resources in the United Kingdom, including both occupied and unoccupied beds, were estimated at ‘well over 300,000 beds’ for ‘air raid casualties and Service casualties as well as any other patients requiring immediate treatment in hospitals’, but it was emphasised that staffing would present a serious problem if all these beds had to be used.
Fortunately, these estimates were not tested. It was never necessary to repeat the mass turn-out of sick people which had caused so much hardship in 1939. The ultimate reserves, such as public schools and
even day schools, public halls and tents, were at no time called into service, and most of the other reserve beds remained in store.
Throughout the war, the quantitative demands of the Armed Forces and of air raid casualties on the emergency medical service remained within manageable proportions. In 1943 the number of beds which the service undertook, if needed, to make available for military patients was 125,000, equal to about one-half of the total number of beds in its hospitals. At that time the number of beds in these hospitals which were occupied by military patients was in the neighbourhood of 23,000. In 1944 it was decided to increase the amount of accommodation to allow for the reception of battle casualties from the Continent, but the clearance of civilian patients from beds and restrictions on admission of new civilian patients for this purpose were gradual processes, well planned in advance.19
It was, of course, inevitable that these operations should lead to hardship among the civilian population and to more complaints about the lack of hospital facilities; but compared with what had taken place in 1939 the dislocation of the hospital services in 1944 was on a small scale. The reception of casualties from the Continent by sea and air proceeded smoothly and never, at any time, overwhelmed the resources of the emergency medical service. At the end of 1944, 38,800 Service patients and 1,900 civilian casualties were in its hospitals.20 By then, however, the Army had established its own field hospitals on the Continent, and its demands upon the emergency scheme gradually diminished.21
Even in 1944, when the invasion of Europe was under way and the emergency hospital scheme hospitals received a greater number of battle casualties than ever before, the chief concern of the hospitals still centred round the needs of civilians, casualties and sick alike. The difficulties of London hospitals in meeting these needs were increased when the enemy’s flying-bomb attack opened in June. There were, however, enough beds for all civilian and Service casualties.
Meanwhile, as the measure of this weapon was being taken, plans were rapidly drawn up to meet the formidable threat of rocket attacks. It was proposed to evacuate about 28,000 patients from emergency medical service hospitals in London, and a further 8,000 patients, mostly aged and chronic sick people, from other London hospitals. On 27th July 1944 the War Cabinet decided ‘that steps should be taken forthwith to move patients from London hospitals to hospitals in other parts of the country’. Seven days later the movement began, and by the end of August over 14,000 patients and 1,600 staff had
been transferred, more than one-third to hospitals in Scotland, and 28,000 vacant beds in the London region were ready to receive casualties. When the hospital evacuation programme had proceeded thus far, a rocket assault on the scale originally feared was no longer regraded as probable and the flying-bomb attacks were fast subsiding. The rest of the programme was, therefore, cancelled.
With the removal of restrictions on the admission of civilians to hospitals in September 1944, the emergency medical service entered the first stage of its demobilisation. Its winding up was a slow and complicated affair.; It could not discard the obligations it had assumed to its wartime patients without solving many intricate financial and administrative problems. Attempts to return to the pre-war order of things proved as futile in the hospital world as elsewhere, and continuing shortages of staff, equipment and buildings made the transition from war to peace a period of disillusionment. It was soon found that the post-war hospital service, despite the wartime extensions and additions, was not large enough to meet all the demands that were made upon it.
(ii) Scope and Quality of the Emergency Medical Service
This chapter has so far been concerned mainly with quantities—numbers of beds, hospitals and patients—little has yet been said about the growing responsibilities and rising standards of the emergency medical service. As the war went on, new classes of patients were included in the service; new facilities and special scheme of treatment were added; the quality of hospital care improved, and administration became more efficient. In particular, the need for closer relationships between the different hospitals and between different forms of medical service was repeatedly demonstrated by experience. Gaps were filled which had been tolerated before the war; the latest methods of treatment were made available on a wider scale; and many were the efforts to bring about continuity of care for the individual patient. Despite all the difficulties of the times, the trend was towards providing a better and more complete service for a section of the population.
The extension of responsibilities was not, however, a planned development. As the nation became more deeply involved in the war, it was increasingly difficult to distinguish between ‘combatants’ and
‘non-combatants’. War workers were as important as soldiers, and key worker in an aircraft factory was almost as precious as a pilot. It seemed absurd, for instance, to restrict special facilities for fracture treatment to the victims of enemy attack while injured industrial workers needed them just as much.
The Ministry of Health’s policy concerning ‘eligibility’ for the emergency hospital scheme was one of compromise and adaptation. It reflected all the hesitations and conflicts of a service which was national only for the time being and for a limited purpose, and which, after accepting responsibility to care for war victims, had to face the fact that the dividing line between its field of action and that of the ordinary hospital services was no longer clearly discernible. Nevertheless, the Ministry accepted new responsibilities only with reluctance. It had no mandate to provide a comprehensive national service, and it did not wish to disturb unduly the balance of interests in the hospital world. The pressure of circumstances led, however, to more and more classes of patients being permitted to use the emergency medical service. But the way in which these developments took place, and underlying conflicts in hospital policy, inevitably introduced a complicated network of administrative and financial regulations. These regulations were, for the most part, inherited from a pre-war hospital service which was neither national nor free of charge and which originated, in both its voluntary and public branches, from efforts to take care of the poor and the destitute.
It is impossible, in a few paragraphs, to convey even a general picture of the subtle distinctions, sub-divisions and microscopic countings which were bound up with the question of eligibility for the emergency medical service.22 A sixty-two page booklet was published for no other other purpose than to define the different classes of patients—there wee twenty-six main classes at the end of 1944—and to determine who paid the cost, to whom, and in what way; each class and sub-class.23 Some people were entitled to free services; e.g., members of the Forces and air raid casualties; others were ‘assessed in the usual way’. Some were the responsibility of public assistance authorities and some were not. Some became so only after a certain period of stay in hospital. Some were E.M.S. patients first, and when their wounds were healed they passed into a different category for the treatment of their ordinary ailments. Some, like merchant seamen, had different rights when they were away from their homes. Some conditions, like fractures, were mostly—but not always—a matter for the emergency medical service. Among patients transferred from one
hospital to another there were various groups to which different rules applied. Some were transferred as as to free beds for casualties. Some were transferred for their own safety. Some were transferred for their own safety. Some were transferred from public shelters and had the right to be treated free of charge during their first three months in hospital. And there were other classes besides, to whom other rules applied.
These financial distinctions and discriminations affected many of the patients treated by the emergency medical service. Then there was, of course, the question of the responsibility of the sending and the receiving hospitals, of the local councils in the home and the reception areas, and of the Ministry of Health and other Government departments. For some classes the Ministry itself paid the cost. For others it accepted temporary responsibility and, later, attempted to recover its outlay from the appropriate local council. where a local council in a reception area paid certain costs—the cost of burial, for instance—the position was reversed; the local authority recovered its outlay from the Ministry. Procedures and accounting forms differed according to the types of hospitals and councils concerned. Inevitably, there were the usual borderline problems and the usual disputes about responsibility.
The results of all these efforts to organise and maintain a ‘tidy’ administration was, in many respects, the opposite from what was intended. A hospital in a reception area, for instance, might receive patients from a dozen or more different areas; some of the patients would be handled as ‘public assistance cases’; others would strongly object to being treated in that way. Some would receive pocket money and some would not. Others would receive more or less than they had been accustomed to. Most of them, however, would ultimately and in some form remain on the books of their own local councils which might be several hundred miles away. Many councils were unable to keep track of all the people for whom they were responsible (some might have been transferred from one receiving hospital to another), and all these authorities found it difficult to keep up to date with the mass of rules and regulations upon which their obligations and claims rested.
This situation illustrated what happens when circumstances change but methods remain the same. There were instances when the Ministry could no longer undo the knots that he been tied it had to resort to using a knife.24 But, in general, the network of confusing claim and counter-claim was formally maintained until the end of the war when it had to be disposed of wholesale with the help of rough estimates rather than exact accounts.
Where the Ministry, the hospitals and the local authorities cannot provide detailed records, the historian is even less able to present a documented balance sheet. It is safe to assume, however, as it was assumed in an earlier chapter on local government boundaries, that the financial results by themselves did not justify the immense effort of maintaining the whole paraphernalia of assessments, means tests, forms and bookkeeping. On the human side, there was a balance of confusion and hardship about which more will be said later.
The history of evacuation offers many parallels to development in the responsibilities of the emergency medical service. The two experiences show broadly the same features. New situations arose and the logic of events compelled the authorities to take action which went beyond the limits originally fixed. Meanwhile, the framework of the administrative machinery, centrally and locally, remained in its original form. For reasons deeply embedded in history, there was strong resistance to changes in structure and function; but here and there, under the pressure of circumstances, resistance gradually weakened. Each individual step seemed insignificant, but the sum total of them all produced a new situation.
The extension of the responsibilities of the emergency medical service had all the characteristics of this process; advances were made against many obstacles leading, eventually, to important developments in the field of hospital care. The list of ‘eligible classes’ grew from Service patients and civilian air raid casualties to transferred war workers, people with fractures, firemen, workers at agricultural and timber camps, and many others. For each addition, the argument for inclusion was obvious. Transferred munition workers, for instance, lived in billets and there was often nobody to nurse them when they fell ill. In the autumn of 1940 the Ministry of Health decided to contribute financially to district nursing associations for the express purpose of ensuring their services for this group of workers.25 It was soon found, however, that this did not offer a complete solution, and the next step was the inclusion of transferred war workers in the emergency medical service. The Ministry went so far as to ask hospitals to accept such workers even when all they needed was ‘sick-bay accommodation’.26 Evacuated people were in a somewhat similar position. Originally, only unaccompanied children had been eligible, but early in 1941 all evacuated and homeless persons were included.27
The E.M.S. fracture service, created for the treatment of the war injured, was soon made available for ‘certain classes of industrial
workers’.28 The purpose was to include all those ‘whose rapid recovery is essential to the interests of the community regardless of the mean by which their injury was incurred’. By the end of 1942 it was discovered that this service was not being sufficiently used for industrial injuries, and the Ministry of Health appealed to all hospitals to report such injuries for special treatment.29 After another interval of time—in April 1943—the service was made available to all manual workers employed in the industries of wartime Britain.30 A few months later, not only fracture but dislocations, sprains, head injuries and severe burns were included in the treatment offered.31
Speed in the provision of hospital treatment was a problem for which there was no general or automatic solution. Queuing—sometimes for three and four hours—in the out-patient departments of hospitals could not be abolished by circular. Nevertheless, complaints from industry and the Ministry of Aircraft Production about the time lost by key workers could not be ignored.32 In some places private arrangements had been made between factories and hospitals for priority treatment of certain categories of workers. For months the Ministry of Health struggled to evolve a general scheme on the same principle. Tact and caution were needed to avoid offending patients, hospitals and doctors. Those who were given priority had to be carefully defined. Ultimately, a solution was found and the ‘Scheme for the Priority Treatment of Key Workers’ was launched in August 1943.33
Although its responsibilities continued to grow, the emergency medical service at no time covered more than a small proportion of the civilian population. Nevertheless, in rendering these additional
services it encountered many of the domestic and social problems of civilian life. With the advent of air raids these problems began to exercise an increasing influence on policy. The hospitals had prepared for the admission of large numbers of patients but it had not been foreseen that, under war conditions, the discharge of patients would also involve responsibilities. Some patients had no homes, no families to take care of them and no facilities for convalescence. In reception areas, discharge from a hospital often meant a choice between returning to a bombed city of finding a billet—and billets were not usually suitable for convalescence. In addition, there were the age old questions arising with illness and incapacity: children left at home had to be cared for; financial difficulties had to be overcome. Each patient, in fact, had his own individual troubles for which some kind of solution was needed.34
It had always been the task of hospital almoners to attend to the social needs of hospital patients but not all hospitals employed almoners, and not all almoners devoted sufficient time to this side of their work. Hospital boards tended to regard them chiefly as assessment officers to obtain financial contributions from patients. In December 1940. the Ministry of Health took the decisive step of asking all hospital admitting a substantial number of emergency medical service patients to employ almoners. It pointed out that ‘the need for the services of an almoner is accentuated by the problems created by air bombardment’, and that almoners should be concerned not only with the assessment of means but with ‘the whole range of services which a trained or experienced almoner renders towards the social welfare and after-care of the patient’.35
This was a new approach. It was quickly followed by as further request to these hospitals. They were asked to see that civilian casualties had home to return to when they were discharged. In the past, few hospitals had shown much interest in a patient’s home conditions; indeed, the lack of knowledge about a patient’s environment had been one of the deficiencies of hospital care which a sketchy almoner service had not been able to remove.36 It is true that the Ministry of Health circulars represented only a modest start and could not change the situation overnight; but they strongly reflected one of the new trends in wartime hospital policy. Here, as in other fields, the outlook was changing; the patient was no longer a ‘case’, a disarticulated
collection of systems and organs, but was beginning to be regarded as an individual in a particular setting needing particular kinds of help.37
This new emphasis on the social needs of ill people was most clearly demonstrated in Scotland by the practical application of generally accepted principles. In 1943 the Scottish Department of Health published the first results of certain experimental scheme it had sponsored.38 Two of these scheme were developed when it was apparent that only a small proportion of the available emergency hospital accommodation was needed for casualties.39 It was decided to use the surplus hospital beds for special purposes rather than allow them to remain empty. As the Department was the owner of six large modern hospitals with over 7,000 beds it could carry out its decisions without the delays and difficulties of prolonged negotiations with various hospital authorities. One of the first measures introduced—the admission to these emergency scheme beds of patients from waiting lists of voluntary hospitals—is discussed later,40 chiefly because it is a better example of effective hospital work for sick civilians than an instance of the social approach to sickness.
Perhaps the most important of these experimental schemes was the ‘Supplementary Medical Service’, widely known as the ‘Clyde Basin Experiment’ from its origins in that area early in 1942. It was then limited to workers under twenty-five years old, but at the end of the same year it was extended to include war workers of all ages in the entire Scottish industrial belt. General medical practitioners were invited to refer patients, about whose health they were concerned, to the regional hospital officer for examination by a panel of emergency medical service specialists. Where necessary, patients were admitted to E.M.S. hospitals for observation and treatment or to auxiliary hospitals for rest. Their social circumstances were carefully investigated, and particular emphasis was placed on the relationship between the patient’s health and work. The main purpose of the scheme was to prevent a breakdown among workers with general and recurrent ill-health by investigating and removing the physical, psychological or social causes.
For success, the scheme demanded cooperation from a number of people, and the Department of Health enlisted the help, not only of the general practitioners who selected patients and who were kept
informed of their progress, but also of employers and the Ministry of Labour. The number of workers included in the scheme was comparatively small,41 partly because it was an innovation, and partly because many men and women hesitated for various reasons, to take advantage of it. The practising doctor’s traditional suspicion of anything resembling ‘State medicine’ may also have played part. For the patient, the limiting factor was often money. The scheme provided for the payment of subsistence allowances and travelling expenses, but this did not compensate those with family responsibilities for the loss of wages. There were also some people who ‘did not feel ill enough’ to accept the proposed treatment, and on the whole it is probably true to say that the majority of both doctors and patients were not sufficiently informed or convinced of the benefits of the scheme. This did not make it any less valuable for, in addition to helping people who needed treatment, some useful lessons were learnt from this wartime essay in preventive medicine.
The Clyde Basin Experiment has been described as an example of a fresh attitude of mind, for which the emergency medical service provided the means of application and the prevailing shortage of manpower an opportunity and an incentive. Other experiments in Scotland, concerned with the ‘follow-up’ of men and women invalided out of the Services and the rehabilitation of disabled miners,42 were carried out in the same spirit.
The existence of the emergency medical service made possible a new approach to many of these problems of sickness and disability in England and Wales as well as Scotland. Advances of both a general and specialised nature took place from 1941 onwards in many departments of medical and hospital work. Some, like the development of the fracture and rehabilitation services, were visible to a wide public; others, like the creation of a national pathological service, could appreciated only be experts. The emergency medical service was also the means whereby a large number of individual, self-sufficient hospitals approached closer to the conception of a hospital service. The pattern—regionally grouped hospitals with specialist centres—was based on a new idea; a division of labour between all the hospital and medical resources of a region. Large general hospitals provided a
number of the more frequently needed specialist services while highly specialised centres for particular forms of treatment and research were attached to certain hospitals at convenient points in each region. This arrangement demanded a high degree of cooperation between all participating hospitals. It offered, as advantages, the concentration of special skills and equipment in certain places, a better distribution of patients and staff according to needs and resources, and a more economic use of the less common and more expensive hospital facilities.
For these reasons, more people than ever before received the benefit of these services and the door was opened to their further expansion. Gaps were discovered and filled. Special committees were appointed to advise the Government on methods of development.43 New ancillary services emerged which, as Chapter V has shown, had previously been non-existent or unevenly.scattered over the country. A great national service of pathological and public health laboratories took shape, and a national blood transfusion service was created the significance of which went far beyond its immediate purpose of saving the lives of civilian and Service casualties.
The story of these and other developments which helped to raise the standard of Britain’s hospital services will be found in the Medical History of the War and in the reports of the Medical Research Council and Government Departments. This volume is concerned simply with their social implications. Paradoxically, when human lives are cheapest, the desire to preserve life and health is at its highest. Wasted and neglected lives became ‘manpower’, and the injured limbs of miners are discussed at Cabinet level. The Government, by establishing a framework for hospital cooperation and by backing it with the resources of the community, made possible the furtherance of these desires. The results, when measured against advances in hospital work during a similar period of time before the war, were revolutionary. But here, as always, the inheritance of the past made itself felt. The conception of local self-sufficiently, though healthy in many respects, was often a hindrance to much that was needed for the better treatment of sick people.
The movement of patients from one hospital to another in the emergency medical service was not simply and solely a wartime expedient for sending people away from areas threatened by air attack. It was in some senses a new principle, based on the idea that a patient should go to the hospital best suited to his needs. Whenever hospitals operated as individual units, cooperation was haphazard; these was not only duplication of effort and resources, but even competition among neighbouring hospitals. This dissipation of strength was
intolerable in time of war. But in creating a new organisation, the Ministry of Health could not immediately remove the ingrained customs of the past, especially as most hospitals expected to revert to something like the pre-war practices at the end of hostilities.
Neither the doctors nor the hospitals were ready to accept, as a normal feature, the transfer of patients suffering from certain types of illnesses or injuries. Sometimes, it was simply a matter of adhering to custom. But often there was opposition; sensible and soundly argued in some instances, irrational and incoherent in others. not unnaturally, many doctors were loath to part with their patients; they regarded the transfer of patients to special centres as an indirect reflection upon themselves and their competence. In any event, it would indeed have been a bad sign had doctors not been anxious to maintain touch with their patients. Hospitals, particularly those relying on voluntary donations, feared that their good will might suffer if they admitted that some of their patients could get more skilled attention elsewhere. The patients themselves often had a strong feeling of loyalty to their local hospital. They also objected to being sent far from their homes, or having to attend distant out-patient departments, partly because the reasons were seldom explained to them, and partly because the Ministry of Health had failed to make adequate provision for travelling expenses, visitors’ meals and other needs.
The defects and lack of uniformity in hospital records were other obstacles in the way of smooth inter-hospital cooperation. When patients are transferred, good records are one of the most important means of ensuring continuity of treatment and accurate assessment of results.44 But hospitals were not usually accustomed to making reports on the people in their care; their records were often deficient even for accounting purposes. It was a standing grievance among general medical practitioners that they lost contact with those of their patients who had been referred to hospital, because many of the hospitals failed to report back to the patient’s own doctor. When the emergency medical service introduced a simple postcard scheme merely to keep track of evacuated sick people it was generally ignored by the hospitals.45 Another such scheme, introduced to check the effects of certain methods of treatment, was only partially successful.46
But against the disappointments and setbacks experienced by the emergency medical service has to be set the record of its practical achievements. In many respects, the story of the wartime fracture and rehabilitation services reads almost like a parable because it typifies the obstacles and advances which have so often filled these pages. It is a long story and only a few of its most characteristic parts can be related here. The idea itself was not new. Rehabilitation methods had been developed during the First World War, but they had been forgotten, along with many other good things, when the spirit of urgency evaporated and manpower was once more ‘surplus labour’. The word ‘rehabilitation’ has been defined in various way and associated particularly with fractures and other orthopaedic conditions but, ‘in its widest sense, rehabilitation of the sick and injured means the process of restoring them, in the greatest measure possible, to health, working capacity and social independence’.47 It is a processs which transcends the field of medical or surgical ‘case’, but as a human being; a study of his home conditions, his work and his aptitudes, his family problems, and his particular physical and psychological handicaps. The first purpose of medical rehabilitation is ‘to prevent disabilities from becoming disablements’.48 This requires the cooperation of the patients from the start, and not just at the stage of convalescence when body and mind have become inelastic and passive.
The birth of the Government’s rehabilitation services was slow and painful. For proper growth, these services demanded all the things that were most difficult to obtain and to achieve: the prompt transfer of patients to special centres, the organisation of careful records and ‘follow-up’ schemes, the provision of fares and meals for out-patients travelling long distances, the employment of experienced workers to investigate patients’ social circumstances, the provision of adequate equipment and space for training, the appointment of specialised medical and auxiliary staff, and the close cooperation, locally as well as centrally, of a number of Government Departments including the Service Departments and the Ministries of Health, Pensions and Labour.
For the orthopaedic services the war marked a new beginning. There had been ‘tragic evidence of the inadequacy’ of the per-war services, even for children.49 In 1935, the report of a British Medical Association Committee showed some disturbing facts and made a
plea for special fracture departments.50 A little later, the Delevingne Committee was appointed by the Government; it published an interim report in 1937 and a final report in the middle of 1939, and it left no doubt about the justification of earlier criticism.51 Fractures were still being treated mostly in general surgical wards, and a ‘radical change’ in this ‘gravely defective’ system was said to be necessary. At that time there were over 200,000 fractures annually, a third of them needing in-patient treatment. War injuries were expected to add greatly to this number and to include a high proportion of complicated fractures.
In September 1939 the Government’s plan for segregation and care of war victims needing orthopaedic treatment were still largely on paper,52 and it was not until the end of the year that orthopaedic centres, under the supervision of orthopaedic surgeons, began to take shape within the framework of the emergency medical service. About half of the centres were attached to existing orthopaedic hospitals and all were situated in the safer areas. Early in 1940 there were nineteen such centres in process of formation in England and Wales and five in Scotland. The Health Departments, through their consultant advisers in orthopaedics, arranged for the appointment of expert staffs and for the supply of rehabilitation material and equipment.
Developments were slow, and those in authority who urged more drastic action, above all the linking of these centres to existing fracture departments in other hospitals, were temporarily overruled. By the middle of 1940, when the Government was still estimating bed requirements for air raid casualties and Service patients at a minimum of 300,000 and when sixty to seventy percent of air raid casualties were expected to require orthopaedic treatment,53 the number of beds attached to orthopaedic centres was less than 15,000.
This was one of the reasons why an Inter-Departmental Conference was appointed in the summer of 1940 to review the problem of rehabilitation.54 When starting its work, the surprising discovery was made that the Treasury had not at the time agreed to the treatment of civilian casualties remaining a government responsibility after the war. Because of the obvious impossibility of any other arrangement,
the conference based its recommendations on the assumption that the Treasury would eventually agree.
The conference was seriously concerned to find that in many instances casualties ‘remained in hospitals not staffed or equipped to deal properly with their particular injury’, and it believed that only ‘constant vigilance’ could ensure prompt transfers. To exercise this was mainly the task of the regional medical officers and the Ministry’s advisers on orthopaedics. A departmental minutes in January 1941, commenting on the report, recommended ‘perpetual visiting and worrying all the hospitals’. Not only civilian but Service hospitals were among the offenders; the natural reluctance of the Services to pass their men on to specially equipped and staffed centres run by civilian authorities was a real difficulty.
In March 1941 an emergency medical service group officers’ meeting was still obliged to put on record that fractures are ‘at present badly treated’, and it was added that the orthopaedic centres were full to capacity. Demands had increased with the inclusion of civil defence and industrial workers in the fracture services. The problem of dealing with the total demand now became not only one one of quantity but also of the location of the centres. These had been established in the safer parts of the country and, in consequence, there were no ‘follow-up’ arrangements for persons who had completed their in-patient treatment and had returned to their homes in the bombed cities. What was needed was a fracture service of much larger proportions reasonably accessible in all areas of the country.
The year 1941 was a year during which great strides were made towards these objectives. The manpower shortage began to make itself felt and rehabilitation—in a wide sense—became a watchword, the most fashionable word in medicine, covering many ideas and purposes. The orthopaedic centres, which remained the most highly specialised units, were quickly supplemented by several hundred fracture departments and clinics of three types, fulfilling different functions and representing different degrees of specialisation. But it was not only medicine that was concerned. In October 1941 the Minister for Labour announced an ‘Interim Scheme for the Training and Settlement of Disabled Persons in Industry’, mainly designed to train partially disabled persons for war work, and providing for various kinds of training facilities and allowances. Under this scheme, hospitals were linked to employment exchanges and training centres to hospitals. Ministry of Labour officials interviewed patients in hospitals and arranged for their subsequent training and employment on the basis of medical advice. Emergency medical service specialists visited centres to assist in choosing the right kind of occupation for those in training.55
These were interim measures, limited in extent and tentative in approach, but signalling a departure of great significance. Meanwhile, the Tomlinson Committee was reviewing the whole field of rehabilitation. In November 1942 its report was published56 and accepted by the Government.57 It recommended an extension of rehabilitation methods to all areas of the country, and to other patients besides those with fractures—medical and surgical patients, the blind, and people suffering from tuberculosis, neurosis and other illnesses. Many of its recommendations simply confirmed what was already accepted or even practised. The report as a whole, however, formed a comprehensive plan for attacking on a national scale the social and medical problems of disablement.
The Ministry of Health was in a key position for taking action on the plan. It reacted by sending its representatives to hundreds of hospitals to investigate the possibilities of development. By 1943 this ‘rehabilitation survey’ was complete, and all the selected hospitals were asked to appoint rehabilitation officers.58 Large quantities of equipment, clothing and material for physiotherapy and occupational therapy were ordered, and by the end of the year over 400 hospitals had received supplies and others were provided with prefabricated huts for gymnasia or with grants and licences for structural adaptations.59 Simultaneously, training courses for doctors and physiotherapist helped to meet the acute shortage of properly qualified staff, and a special Ministry of Health memorandum advised all hospitals on the methods they could adopt for playing a part in the rehabilitation scheme.60
By the end of 1944 the number of hospitals employing rehabilitation methods had almost doubled compared with the previous year.61 A daily average of some 31,000 persons—20,000 of them out-patients—were benefiting from these services in emergency scheme hospitals during the first half of 1945.62 With the passing, in 1944, of the Disabled Persons’ (Employment) Act, providing for the setting up of a disabled persons’ register and for the appointment of disablement rehabilitation officers at employment exchanges, the administrative machinery for an organised medical-social approach to the problem of disablement was in most essentials established.
It is difficult to arrive at even broad conclusions on the degree of success achieved during the war in the field of rehabilitation. There are no figure to show how many fractures were still being treated in general surgical wards during the later stages of the war, or how many patients slipped through the net of the new machinery into a state of dependency and hopelessness so frequent before the war. An impressive account of methods and resources can never be conclusive evidence that they have been—or are being—properly used. A hospital possessing rehabilitation facilities may use them well and whenever they are needed, or it may use them inexpertly and on a limited scale.63 A rehabilitation officer may exert all his skill and energy, or he may fill his post only in name. There is no doubt that in some hospitals very high standards were reached, and that the orthopaedic centres and special fracture units had a great record of success.64 It is also certain, however, that taking the hospital services as a whole in all areas of Britain high standards of rehabilitation were not very common.
It could hardly have been otherwise when allowance is made for the general lack of rehabilitation facilities before 1939, and for all the difficulties of organising a nationwide service in the midst of war and bombing and a great shortage of material resources. Although only a limited group of hospital patients benefited from the wartime advance, nevertheless, an immense amount of constructive work was achieved by the hospitals in less than five years. The creation of a framework for a national rehabilitation scheme may thus be recorded as one of the chief successes of the Government’s emergency medical service.
Before this account of the problems and achievements of the service is brought to an end, one other subject of particular importance to the social historian demands some attention. In this matter—the matter of patients’ meals in hospital—as in many others, the imperative pressures of war forced into the open the need for reform.
Hospital food, as a branch of medical care, has long been noted for its low standards. The historical association of hospitals with poverty represents, perhaps, the chief cause; another contributory cause has been a lack of interest in the subject among doctors. Medical staffs have not usually regarded food as an essential part of hospital treatment unless a particular illness needed a particular diet. Many patients therefore received food not only inadequate in quantity but
unsuitable in quality.65 At the end of 1944, it was still true to say that ‘though a few hospitals can fairly take pride in the meals they provide, they are only exceptions to a thoroughly bad rule’.66 Not many hospitals employed dieticians to arrange balanced meals and special diets. When more tried to do so towards the end of the war it was soon learnt that there were not enough qualified people to go round.67
The immediate effect of the war was to lower still further the standard of hospital food. The habit of relying on visitors to provide not only extras by necessities of diet became even stronger.68 The situation created by shortages of food and rationing quickly showed up all the weaknesses of rough and ready methods of catering. Most housewives learnt that rationing demanded careful planning and more effort in the preparation of meals. The hospitals, however, found it difficult to adapt themselves to the drastic changes in the food situation which the war imposed. They needed, not only more and better qualified staffs and more kitchen equipment, but a new approach to the task of feeding sick people. In all too many hospitals food was regarded as an item of secondary importance which should cost as little as possible.
As a result of either economy or bad distribution many patients did not even get their full rations.69 In a number of hospitals social distinctions were made in the standard of meals served to officers and other ranks of the Armed Forces and to patients in private and public wards.70 There was also an officially prescribed distinction involving different ration scales for Service patients and civilians.71 This caused difficulties for hospital caterers, and in surroundings where all the
people were engaged on the same job of getting well it was often felt to be unjust.
The Ministry of Health, in directing the emergency hospital scheme, discovered that food was one of the many hospital matters with which it had to concern itself. At first, the Ministry lacked both information and experience. Moreover, as food was a question of internal hospital administration it could not direct; it could only advise, persuade and tactfully suggest.72
The difficulties and complaints about hospital meals which reached the Ministry were dealt with either by the regional hospital officers or by its own food expert when visiting hospitals. Through these channels, and as a result of letters of complaint from patients, members of Parliament and others, it became apparent that the authorities of many hospitals needed—and were beginning to seek—informed advice and help. In May 1942 a handbook on ‘Wartime Feeding in Hospitals’ was published by the Ministry. ‘Experience has shown’, stated the introduction, ‘that the food provided in many hospitals is unsuitable, badly cooked and badly served, with the result that the patients’ recovery is delayed’. It went on to say that ‘suitable meals, well cooked and attractively served, constitute as important a part of the treatment as careful nursing and skilled medical attention’. The handbook advised hospitals on the organisation of catering departments and on the best way of utilising the available rations.
It is difficult to estimate to what extent this advice was followed by hospitals. In February 1943 a Ministry of Health circular to regional officers reviewed the results of a number of inspections and concluded: ‘In some instances patients are not receiving their fair share of the ordinary rationed and unrationed foods, the inference being the that the diets of the staff are enriched at the expense of the patients’. Hospital officers were asked to report the most obvious instances known to them for special inspection. In 1944 the Ministry added to its staff three dieticians to inspect and advise hospitals and other institutions. As a result, serious deficiencies in diet were discovered about which a number of hospital managements had no knowledge.
Meanwhile, King Edward’s Hospital Fund for London was carrying out certain valuable investigations. With the help of the Ministry of Food, the diets of patients and staffs in three general hospitals in the London area were carefully analysed. When the fact were published in 1943 the hospital world received something of a shock.73 It
was generally known that hospital food was often unsatisfactory but the extent of the deficiencies had not been realised. In the cautious language of the memorandum theresults of the survey were described as disturbing, although not necessarily typical. This publication received greater attention from hospital managements and medical staffs than the inconspicuous but more extensive activities of the Ministry of Health. King Edward’s Fund followed up this work with a further memorandum in 1945 containing advice and detailed recommendations.74 It also assisted hospitals by organising training courses in hospital catering.
All these efforts led to improvements during the later stages of the war. The fact, too, that war conditions made hospital more accessible—and likewise sensitive—to public opinion was a contributory influence. As a result, many hospital authorities became conscious of the need for reform. It was accepted that balanced, well cooked and attractively served meals suited to the needs of each patient should form an essential part of hospital treatment.
These developments in hospital feeding, like the advance in the field or rehabilitation, are illustrations of war stimulating progress because of the greater need for patients to recover from their injuries and illnesses as quickly as possible. But while the circumstances of war created this impulse they were, simultaneously, the cause of conditions which made it hard for action to follow. This was particularly true where hospital feeding was concerned; moreover, the desire for change came late in the war when shortages were greatest and when it was most difficult to improve kitchen and catering equipment and to find qualified staff.
In other fields of hospital work the barriers to practical action were perhaps a little lower, and the driving forces more powerful. The development of the public health laboratory and blood transfusion service were conspicuous instances of advance accomplished despite countless restraints. But all the time the Health Departments were struggling, not only to bring about better services in the emergency hospital scheme, but to prevent wartime restrictions and shortages from causing a deterioration in standards. The time came, however, when part of the hutted hospital programme had to be abandoned; when all schemes for repairs and alterations were ruthlessly pruned; when supplies of equipment had to be carefully husbanded, and when hospital had to fight not only for each doctor and nurse, but for each porter and kitchenmaid.
It was in the face of all these hostile forces that the emergency hospital scheme had to discharge its responsibilities as a war-operational service. Had the demands upon it been as heavy as was
originally feared, it would almost certainly have broken under the strain. Had it not been national in scope, with power to influence the distribution of national resources, the story of hospitals for war victims might have made a depressing record. In fact, it is for the most part a record of achievement and progress.
When the last test came in 1944 the emergency medical service passed with flying colours. It was elastic enough to expand and contract according to the needs of the moment, and it was sufficiently equipped to offer a comprehensive service of high standard to the sick and injured of the Armed Forces. The progress of a generation seemed, at that time, to have been compressed into a period of less then five years.
The success of the emergency medical service for war casualties cannot be doubted. But success in war is almost always bought at a price, and this service was no exception. An attempt will now be made to add up the social costs, to reckon the bill, and to explain how it was paid and by whom.