MEDICAL INSTITUTIONS. (Hansard, 29 July 1889)

LORD SANDHURST,
in rising to move, "That the prayer of the said Petition be agreed to," said: My Lords, I would say, at starting, that I have assumed this task with feelings of great diffidence, and I wish that the task had been undertaken by some noble Lord on either side of the House who was more practised in the ways of your Lordships' House, and with greater facility of expression, and also whose individual opinion in endorsing the Petition would carry more weight. My Lords, the subject is one of great difficulty, and the more it is considered the more complex and difficult it becomes. It concerns the welfare of the general public in receipt of medical relief, and it also concerns those of the public who generously contribute to maintain the charities. Moreover, the subject is bound up with the interests of the most honourable and honoured of professions. Therefore, in default of a more experienced advocate, and being not entirely unacquainted with the work of the large general hospitals in London, I ask the indulgence of your Lordships while I endeavour to state some reasons why some of us, at any rate, consider an inquiry to be necessary. In my remarks I shall not impugn the policy or management of any individual hospital nor arraign any board, and I do not wish your Lordships to suppose that I am taking up a position as an economist or a philanthropist. I shall merely lay before you facts backed by a few figures. This is not the first time that the subject has been considered. Various Medical Committees have considered the whole or portions of the subject. No action, however, has been taken by the hospitals. 1549 Failing these, information has been amassed by the Charity Organization Society, a Society known to your Lordships, whose business is organising and not dispensing charity, and seeing that this is their business it is, I think, a fit and proper body to undertake it. The medical relief in the Metropolis may be classed under two heads—charity and Poor Law charities. There are 11 general hospitals with schools, and eight general hospitals without schools; 67 special hospitals; 26 free dispensaries; 35 provident dispensaries; 13 part-pay dispensaries; and five surgical appliance societies. The number of in-patients is 76,898; and out-patients 1,470,398. The total income is £696,258, and the total expenditure is £723,021. The beds unoccupied are about 2,000 in number. To these must be added 27 Poor Law infirmaries, with 11,900 beds, and £336,200 expenditure; 44 Poor Law dispensaries, with 114,980 outpatients, and £19,980 expenditure; eight infectious hospitals, with 2,760 beds, and £129,313 expenditure. The total is a follows:—239 institutions—in-patients, 122,047; out-patients, 1,585,353; total expenditure,£l,208,523; total income, £1,197,477, in the year 1887. I beg your Lordships' attention to the fact that for want of funds upwards of 2,000 beds were unoccupied. Perhaps ail the definitions are not clear, and it may be thought I should explain them in passing, though it seems hardly necessary. The term general hospitals with schools would not seem to require explanation. Patients are admitted nominally by letter, but they are practically free. Eleven of them have schools attached, where every sort of disease can be studied. Take, first and foremost, the three great endowed hospitals—St. Bartholomew's, St. Thomas's, and Guy's. Two of these, St. Bartholomew's and St. Thomas's, are of very ancient origin. They were endowed, not by the State or the municipality, but by private individuals, who have given the means for producing the incomes on which they exist, and they do not, or did not formerly, apply to the public. Even of these the income of one (Guy's) was so precarious that two years ago it had to ask the public for £100,000 to enable it to carry on, and at another many beds are 1550 closed, and doubts exist as to their ever being opened again, and certainly they will not be opened entirely for gratuitous patients. Then there are eight other general hospitals with schools. These are the most useful and important schools—all-important for the study of almost all diseases. Their size insures, if well managed, treatment at less expense than the smaller hospitals. They have, for the most part, special departments for special cases, and have the advantage of the very best advice. Some have been able to be structurally altered in accordance with the advance in medical science. In the last 20 years the greatest advances and improvements have been effected in nursing and nurses. In 1887 the deficits of these hospitals alone amounted to upwards of £32,000, and if it had not been for a number of small legacies, with which they were able to pay their way, the deficits would have been upwards of £51,000. So much for the general hospitals. Of the special hospitals, 67 in number, some are special in treatment, but nearly all for special diseases. I am anxious to be moderate, but I must, and will, say what I think, and what those who are with me think. I must also state what I know is the opinion of very large numbers of the medical profession in London. The origin and management of some of the special hospitals have been such as to cause suspicion, where suspicions exist, as to the conduct of hospitals as a whole. They are not unfrequently started for private advantage by those who wish to make themselves consulting physicians or surgeons to them, some are started for speculative purposes, and in neither case is the public welfare or the advance of science considered. They are generally started, as to funds, more or less by some philanthropist, and on that support failing they are thrown on the charitable public. There are no schools; there is no advance of science, and the management leaves much to be desired. Owing to the small number of beds, the administration must be costly. They are sometimes found in insanitary premises, and are built without regard to existing local needs or perhaps in proximity to hospitals; the advice is not of first-rate description, and it is not infrequently the case that there are more beds pro- 1551 vided in the general hospital hard by for the treatment of such special cases than in the special hospital itself. By the names which they assume they deprive the larger hospitals of cases which, in the latter, would be better attended, and from which instruction would be gained. They also attract large sums of money which otherwise would probably find its way to the larger hospitals. My Lords, that is the effect of the evidence which we have been able to collect; but I should like to read to your Lordships the opinions of two individuals—one of them is amongst the foremost of our medical practitioners. The distinguished physician Sir Andrew Clark has vividly described one of the greatest evils in connection with our hospital system in the following words, in a speech at the Hospital Fund Society:— Then there is another reason, and that is the foundation and maintenance of improper hospitals, which divert funds in a direction in which they ought not to be employed, and rob the great hospitals of the support which they ought to receive. A doctor who cannot get on in the ordinary way takes to studying the great toe, and he discovers something about it that has never been discovered before. In the course of his studies he ascertains that the diseases of the organ are not only supremely important in themselves, but that they have the most intimate relation to all the other serious diseases of the body. He also invents a wonderful instrument whereby he can look into the great toe and see what is threatening, and prevent all those terrible things which happen in the organ and affect the whole system. He goes to his friends, shows them his instrument, and tells them of his discoveries. They then club together and establish a Hospital for the Treatment of the Diseases of the Great Toe. This hospital is manned by his friends, who, having joined in the venture, must make it a success. They soon get patients who are convinced of the vast importance of the great toe; marvellous cures are effected, and all sorts of frightful diseases are prevented. They have an annual meeting; they have a chairman, who sets forth, bashfully, in the presence of the great physician, the diseases of the great toe, the wonderful things that have been done, the great service which has been rendered by the hospital, the terrible prejudice it has had to encounter, the determination that this great institution shall be liberally supported notwithstanding the prejudices of the medical profession, and of those who herd along with them. Then, my Lords, I come to another very eminent authority, Mr. Michelli, the Secretary to the Seamen's Hospital Society, and late Secretary to St. Mary's Hospital, who, in a paper which he re- 1552 cently read at the Hospital Association on "Hospital Extravagance and Expenditure," drew attention to the excessive amount spent by hospitals in advertising and collection, printing, stationery, and postage, to the small net percentage of profit that goes to hospitals out of the receipts from bazaars, fancy fairs, and other such means, and to the excessive cost of special hospitals. He says:— But what is grievous to see is a small special hospital established within a few hundred yards of a large general hospital, in the former of which there are fewer beds altogether than there are beds allotted to the particular speciality in the general hospital close by. The maintenance of a bed in the small hospitals is often 50 to 75 per cent greater than in a large one; and I maintain that every penny so spent is wicked extravagance and waste. He then states that he has gone carefully through some 200 Reports of hospitals, and finds that he can get no information from them. Now, my Lords, the cost per head for salaries and wages in the first of the large general hospitals, with school and 205 beds, is £19 1s. 2d.; in the second, with school and 310 beds, it is £25 0s. 6d.; in one special hospital, with 80 beds, £39 7s. 2d., and in another special hospital, with 64 beds, £35 0s. 9d. In a third, with 16 beds, it is £33 4s. 2d., and in a fourth special hospital, with 14 beds, it is £42 10s. 3d. The average cost per head for nine general hospitals with schools, with average number of beds 295, is £24 5s. 10d. for salaries and wages; whereas for the nine special hospitals, average of 27 beds each, it is £30 12s. 2d. Now, my Lords, these institutions obviously call for inquiry, if for no other reason, yet on account of the figures which I have given. At the same time, the fact must not be ignored that there are some exceptions in the case of two or three institutions of world-wide and well-merited reputation. But the very excellence of these makes the case for an inquiry into these institutions all the stronger. The institutions to which I refer were in existence before the general hospital system was as complete as the special Department now is, and long before the hospital system acquired the excellence which it has now undoubtedly attained. Then, my Lords, I come to the dispensaries. There are 26 free dispensaries, most of which were started before the 1553 out-patient system was developed, combining free treatment both at the dispensary and at home. In these there are 162,219 patients, and they have a deficit of £2,003 in an expenditure of £21,257. Then there are the part-pay dispensaries, in which the out-patients number 102,302, and the deficit was £714 on an expenditure of £9,710. Then we come to another class, the provident dispensaries on the benefit society system, to which subscribers pay both in health and sickness, and which afford relief to the whole family. These institutions thrive best away from the hospitals, and are principally on the outskirts of the Metropolis. In these there were 125,674 out-patients, and income and expenditure nearly balanced each other. Then I come to the great question of the finances of these institutions. I should have mentioned that the special hospitals have a surplus of about £90,000. This financial question is a very simple matter, though it is extremely difficult to get at trustworthy figures. In 1887 the hospital deficit amounted to £32,000, and now the total is about £100,000. But in dealing with these figures it might occur that one hospital might have been so lucky as to receive a very large legacy of £100,000. That would give an average surplus, while only one of the hospitals participated in the legacy. I will give an instance of my own experience in hospital finance. A few years ago, as regularly as the quarter came round, the Chairman of a Hospital Committee with which I am connected used to make a motion for the withdrawal of £3,000 or £4,000 of capital for the payment of bills. He was making the usual motion, when I remonstrated, but was immediately answered that I knew nothing of finance. It may have been all right, but it appeared rather startling. The only way in which these general hospitals have been able to get on is by the legacies which from time to time they receive, and by persistent begging. There is no systematic statement of accounts, and if some organized method of furnishing a statement of accounts were to be adopted, it would be more satisfactory for the staff and for the subscribers. Now, my Lords, I come to another subject on which there is considerable diversity of opinion among those best qualified to judge, and that is 1554 the outdoor departments of the hospitals of which the dispensaries are really an extension and development. In 1887 the outdoor patients were more than one million and a half, and the number keeps on increasing. These patients often have an almost interminable time to wait, and I have no doubt that many of them are able to pay for attendance and medicine. This is very hard on the small local practitioners who work hard for small fees, and it tends, I fear, to the pauperisation of a very large number of the community. Therefore, my Lords, I should like to put it to the House whether there is not here a legitimate cause for inquiry, and whether something might not be done to check this pauperising system of outdoor relief, so that those in absolute want would be left to the resources of the larger institutions. Now, my Lords, I come to the Poor Law dispensaries. There are 44 Poor Law dispensaries and eight hospitals for infectious diseases in the Metropolis. There are 27 Poor Law infirmaries, which before 1867 were of a very inferior character, in which the diet and nursing were bad, and the nurses were themselves paupers. But in 1867 an Act was passed which produced a very much better state of things, and now they are magnificent State hospitals, built away from the workhouses, in which every modern improvement is to be found. There is never any want of first-rate medical appliances, there is an enormous amount of air and space, and a trained staff. The system adopted with regard to them amounts to this: an individual, after being seen by the relieving officer, is sent to the infirmary. That is intelligible; but there is no security as regards the distribution of medical relief. I will just take a case which shows the system. In Marylebone alone, with a population of 155,000, there were in 1885—one Poor Law infirmary with 700 beds, one general hospital, ten special hospitals, four free dispensaries, one provident dispensary, two Poor Law dispensaries, and one or two charities for gentlewomen. I should think it very likely that a great number of the patients came from adjoining parishes, while the people in Marylebone went to St. George's and other adjoining parishes. There is no system at present by which we can deal with 1555 that. Then again, take Fulham, which is a long way from the centre of the Metropolis. With a population in 1885 of 152,600, there were one general hospital, two sick clubs, one Poor Law infirmary, and one Poor Law dispensary. My Lords, I have some experience of Committees of your Lordships' House, having sat for two Sessions on an inquiry into this system. I do not think an inquiry into these medical charities would be such a difficult matter. If there was an inquiry by a Select Committee of your Lordships' House, they would have the advantage of the evidence of experts, and would be likely to come to a more rapid conclusion than if assisted by experts in a Royal Commission. I would ask the noble Marquess and the noble Viscount to consider the matter, and if they agree that there should be some inquiry, I think it would be most satisfactory. I have been told that such an inquiry is premature, and one of the principal reasons given is that there are in the air several schemes for the improvement of the system, one of which is linking the provident dispensaries to the general hospitals; another, payment in hospitals; another, payment of fees according to means; another—suggested by the Lord Mayor—that of collecting 1d. a week from the wages of people in workshops. These various schemes would, I think, furnish excellent food for reflection if the inquiry I ask for were granted. My opinion is that if we are to wait until such schemes can be put in practice we might have to wait until a very indefinite period. In my opinion, and in the opinion of those for whom I speak, this inquiry ought not to be delayed. I have no wish to bring forward any Motion which would have the ultimate result of placing these hospitals on the rates, though I have no doubt I shall be told that is the tendency of my Motion by those who do not take the trouble to read my remarks. I think it would be a great pity and a great slur upon this Metropolis if we had to confess that these hospitals were failures, because we could not provide adequate means to support them. It is difficult to see how matters are to go on as they are at present. I have framed this Motion with reference only to the hospitals of the Metropolis, although in the Provin- 1556 cial towns there is a very general opinion in favour of a similar inquiry with respect to their hospitals. I may also say that we have with us nearly the whole of the rising medical profession. I have not put forward any remedy—it would be better that that should come from the Committee when they have thoroughly thrashed out the subject; but I have endeavoured to bring such light as I can to bear on the circumstances in the hope that in the end some system may be evolved from the existing chaos. My Lords, I beg to make the Motion which stands in my name.

* THE LORD PEESIDENT OF THE COUNCIL (Viscount CRANBROOK)
My Lords, I am sure your Lordships have listened with great interest to the speech of the noble Lord on a subject which is attracting very much attention at present, and which has attracted great attention in times past. Nobody, I think, will be found to differ from the opinion of my noble Friend—that if we could provide some central organisation for the charities of this Metropolis or of the kingdom we should be doing a great work and an immense deal of good. The danger is lest, if we were to impose an inquiry, the flow of means to the institutions might not be in some cases checked. When you are dealing with voluntary subscriptions, you must beware of checking them by such a step as my noble Friend has suggested. Hospitals generally possess a fixed income from endowments, and there are a great number of them, I have no doubt, offer a proper subject of inquiry; but it is a very different thing when we come to deal with charities which are receiving aid by subscriptions from day to day. There has been, no doubt, an unnecessary multiplication of special hospitals. But they have been set up and are conducted by those who are breaking no law and infringing no rule of society, and who themselves find the means by which they are carried on. That seems to me to be the great difficulty in interfering with them. My noble Friend has referred to what occurred with regard to the Poor Law hospitals in 1867. Previous to that time there was insufficient attend- 1557 ance, insufficient nursing, and no good sanitation. I can speak myself to haying seen patients in some of the Workhouses lying in a state of dreadful illness two in a bed. But there was a strong feeling in the matter, and with the agreement and concert of all parties a Bill for their improvement was passed, which is, I believe, still in operation with respect to those Poor Law hospitals. With regard to the Motion I can say, on the part of the Cabinet, that the case for inquiry will be considered, and that next Session I may be able to announce to my noble Friend what course the Government propose to take. I can assure my noble Friend that the matter will receive the attention of the Government, and I hope he will be satisfied with that assurance.

THE EARL OF KIMBERLEY
My Lords, I merely desire to say a few words on this subject, because the Committee on which I sat last Session expressed a desire that the Government should consider the whole matter and see whether it would be possible to institute such an inquiry. I entirely agree with the view expressed by the noble Viscount with regard to institutions maintained by voluntary subscriptions; but, at the same time, I should be sorry if that idea should prevent some inquiry into the larger hospitals. An attempt has been made at amalgamation, but it has failed owing to the jealousies and difficulties in the way. Another matter which has not been referred to by my noble Friend is the present condition of the great infirmaries connected with the various Boards of Guardians in the Metropolis. These Poor Law infirmaries have become so important, and are so exceedingly well-managed, as to occupy a very great place in the treatment of the sick. The whole subject is a very large and complicated one, and at the present time I can only say that I am glad to hear the Government are directing their attention to it. An inquiry into the whole subject could not fail to result in considerable advantage to the Metropolis and to the public at large.