PUBLIC HOSPITALS

Evening Post, Volume CX, Issue 31, 5 August 1925, Page 6

PUBLIC HOSPITALS

* ■• PRIVATE WARDS AND STAFFING B.M.A. RECOMMENDATIONS KEPLY OF HOSPITAL BOARDS. The important question whether the time has arrived when it will be necessary to make some changes in the policy affecting the administration of the general hospitals of the Dominion, has recently engaged much attention by the Health Department, Hospital Boards, local bodies which contribute a portion of the hospital funds, and the Press. The New Zealand branch of the British' Medical Association has made certain recommendations on the question. The desirableness of es- . tablishing private wards in connection with tho general hospitals has been urged. The New Zealand Hospital Boards' Association, through its president, Mr. William Wallace, of Auckland, has given a considered reply to the B.M.A. recommendations, and has expressed its opinions on the whole question. The following is, in part, the reply of the executive of the Hospital Boards' Association to the B.M.A. :— "The New Zealand branch of the British Medical Association recently published its recommendations on certain matters of policy in regard to public hospitals. The recommendations have been considered by the executive of the New Zealand Hospital Boards' Association, and formed the subject of a statement by the president, Mr. William Wallace, of Auckland. "It is noted by the published report of these recommendations that the British Medical Association has been asked for its opinion by the Director-GeneraL It is conceivable, of course, that the Direc-tor-General should have desired to know the opiwfcn of the medical profession upon the question of the medical staffing of hospitals, a matter that .intimately concerns it, but whilst Hospital Boards welcome suggestions which show an interest in hospital matters from all concerned, such questions of-lay administration as the number of hospital districts, the financing of hospitals, and the general functions of Hospital Boards, are matters on which the collective opinions of the medical profession cannot in themselves be deemed authoritative. POLICY OF THE BOARDS "For these reasons the views of the British Medical Association on the matter of medical staffing of public hospitals are regarded as forming the most important feature of its recommendations, and in this connection particularly that comment is made. "The association prefixes its recommendations by affirming 'that:— Public hospitals should be so constituted as to be available for treatment of every member of the community. "This will, in the main, no doubt, receive a great deal of support. There is clearly an increasing tendency on the"' part of the public to seek treatment in our public hospitals many of which are nowadays able to afford far better treatment facilities in many respects than are provided in private hospitals. PRIVATE WARDS RECOMMENDEp "At a conference of Hospital Boards' delegates at Wellington in October last, the principle was affirmed of providing private wards is public hospitals so that the public generally could obtain the benefits of the treatment. "Objection to private wards has been expressed on the grounds that their introduction would tend to cause class distinction. Ido not think that such would bo tha case—class distinction now exists and will continue to exist until human nature changes. It possibly exists at present in both public hospitals and privata hospitals where not sternly repressed by the discipline and organisation of the institution. "Admission to such private wards should doubtless be made possible to any person who shows he is able to, and agrees to, pay the full cost of maintenance, including a proportion of depreciation charges, interest on capital, and' administration expenses. t "The full adoption of this policy so far as it is possiblo is, hdwever, a matter of quite gradual development, depending on the influence of several factors (operating to a variable extent in different districts), including the all-im-portant one of finance. The existence of relatively efficient and attractive private hospitals, and also, ho doubt, the present question of medical staffing. B.M.A. SUGGESTIONS "The recommendations of the British Medical Association as regards the medical staffing of public hospitals as I understand them are, in effect, that: — (a) All the medical and surgical work of tho hospital shall be in the hands of medical men in practice in the district under whose direction, however, the resident medical officers of the institution may be permitted to act. (b) Patients.able to pay medical fees as well as hospital fees, and patients who voluntarily enter private wards should be required to make arrangements for attendance by a doctor of their own choice, the fee to be a matter between patients and doctor. (c) Patients other thon those just referred to are to be attended by local practitioners appointed as part-time members of the hospital staff, and remunerated by the hospital board. In the case of the smaller hospitals it is apparently intended that all local practitioners (except those deemed unsuitable by a proposed central controlling board) shall be appointed . arid given the right of "attending their own patients if they so desire. (d) Medical superintendents in the larger hospitals are to confine themselves to administrative work. "It will bo noted that these recommendations resolve themselves into the support of a slight modification of the ■community system of hospitals, as operating in many cases in the hospitals in the "United States, though I believe in connection with only one or two rate supported institutions. COMMUNITY SYSTEM "It would be as well here to point out that the community hosiptal or, as it is otherwise known, the 'open hospital,' is by no means universally adopted in the "United States of America. The Henry Ford Hospital at Detroit, for . instance, is what is known amongst tho profession as a 'closed hospital,' that is, it employs its own team of whole-time and purely stipendiary staff. The efficiency of the Ford Hospial is as unmistakeable as that of all that remarkable man's undertakings. No doubt, he recognised from the commencement the absurdity of entering into a contract with a certain section .of his employees ou such a

vague, unsatisfactoryj and unbusinesslike nature as that obtaining in the community hospital. Whatever the nature' of their employment and service the medical staff of a hospital are as much the employees of the institution as are tho nurses, engineers, clerks, or any other employee. FULL TIME MEDICAL OFFICERS "From the viewpoint of the bulk of the medical profession the proposals may represent an ideal arrangement, but I do not think hospital boards or the puWic generally will regard them with favour. In the first place, it has been the experience of some boards that the .placing of all the medical and surgical work of*the hospita^ in the hands of the medical men in practice in the district has not been entirely satisfactory, mainly owing to the lack of disciplinary (control and jurisdiction, with tho result that these boards have been compelled to appoint full-time stipendiary medical" officers, and it has apparently been their experience that this js a much more satisfactory arrangement. "It is not seen, moreover, how the present recommendation of the British Medical Association in this connection will afford any better means of exercising control over the visiting medical staff. On the contrary, its recommendation is clearly that the work should be in the hands of the medical practitioners entirely. "Furthermore, even members of the profession are divided on the question as -to whether surgical work in hospitals is not better left to medical men who have had the opportunity of obtaining considerable experience than* to be distribtued over medical practitioners in the district, only a few of whom will naturally have that opportunity. "DOCTOR OF THEIR OWN CHOICE" "In regard to the recommendation that patients deemed able to pay should be required to make arrangements for attendance by a doctor of their own choice, this does not commend itself for' the reason, firstly, that in actual practice it would not be possible in the majority of cases to determine especially in advance whether any person should or should not be deemed able to pay. From the viewpoint of the public it is, moreover, not offering the reasonable facilities for treatment in our public hospitals that are desired. When the. principle of private wards was affirmed at a conference ol the Hospital Board delegates held in October last, it was also agreed that patients in these wards be given the opportunity of engaging their own medical advisers, but it was not suggested that any class of person if in need of hospital treatment would be compelled to engage his own medical attendant or should be denied the services of tho hospital medical staff. Any such suggestion of compulsion or restrictions in regards to a particular class of patient does not seem entirely consistent with the desire fo offer the benefits of treatment in our public hospitals 'to the public generally. MEDICAL STAFF If the policy is adopted of opening hospitals to all who seek admission it naturally follows that the medical staft should not be expected' to work therein without remuneration, and the Hospital Boards' Association is in agreement with the recommendation that the medical staff should be paid either partly or in full for their services. This is on the lines of the suggestion made recently by the Director-General nnd approved at a conference of the Hospital Boards' Association in Auckland. In this connection, however, I note that the British Medical Association recommends that in the case of smaller hospitals all medical practitioners (except those deemed unsuitable by a proposed central board; should be given the right to attend their own patients in the public wards if they so desire. No board with any choice in the matter would accept the principle that all practitioners in the district should bo permitted to attend their own patients in its institution. Firstly, because it is necessary particularly as regards patients in the public wards that responsibility for^professional medical attendance be definitely fixed and capable of determination. Secondly, treatment methods -and ideas of internal economy on the part ol medical men are such variable quantities that it might mean possibly playing fast, and loose with the ratepayers' money. THE LARGER HOSPITALS "In regard to the suggestion that in the larger hospitals as far as practicable the whole-time medical superintendents should confine their duties to administration, I may say at once that I am strongly and definitely opposed to such a proposal. Why should a highly-qualified and efficient medical man be relegated to mere routine duties? What is the use ol his clinical training and experience if he iji not to be allowed to avail himselt thereof, and what would be his future ? A considerable amount of explanation 01 this clause of the profession's policy is' required before a considered opinion can be expressed thereon, but, generally speaking, there can be but one professional head of an institution, viz., the medical superintendent, who alone is responsible for the treatment of the patients in the public wards. It is true that to some extent under our present honorary system the medical superintendent is, in the four largest hospitals, an administrative officer, but this is by no means the case in many of our'othcr larger hospitals/ As a matter of fact, insofar as the boards' medical officers exercise no jurisdiction or control over tho various parttime medical officers there exists a fundamental defect, and it has been for this reason chiefly that some boards have been compelled to dispense with the honorary staff and substitute full-time officers." SUMMARY OF POLICY Having dealt at length with the proposals of the other matters in regard to medical staffing, it would be as well to summarise the recommendations of tho executive of the Hospital Board's Association in this connection :— 1. That the hospitals are available to all who seek admission—the poor and destitute to have first right to the beds, and all that the medical practitioners should he concerned with is whether the physical condition of the patient is such as to make him a fit subject for hospital treatment and whether he would benefit thereby. 2. Thai the principle, is affirmed of providing private wards in public hospitals patients voluntarily entering such wards to bn at liberty to engage their own medical advisers. 3. The institution of private wards is a matter that should be left to each hospital board, as also the question as to whether tho board should permit patients admitted to these private wards to obtain the services of tho board's full-time medical officers in lieu of an outside practitioner. Where permission iv not granted the board should preserve the right to approve a scale of fees that may be charged by outside practitioners. 4. That'the honorary staff cannot be expected to give their services free, and should, he remunerated. 5. Thai in no public wards should patients be »ttended by other than the jncdicnl staff appoint c<l by tho bonrcl. 6. That fees diaries in thfi raso of patients admitted to the public wards

should for the present be not raised +.o more than 9s per diem for adults with reductions for children. Patients admitted to private wards should be charged a fee estimated to cover the full cost of maintenance plus extras, and to include a proportion for depreciation charges, interest on capital, and administrative expenses. 7. That in all other matters of internal administration of the hospitals the executive is generally in accord with the model bylaws issued by the Department. 8. There should be no further subdivision of hospital districts, and any future proposal in this direction should,be referred to the executive of the association. 9. The existing methods of levies and subsidies and of representation of contributory local, authorities should not be altered, except that the election of borough representatives should be triennial (instead of biennial) as in the case of counties. 10. Social welfare work, including the administration of outdoor relief, is in its nature closely related to work in connection with fees collections and the treatment of the indigent sick in public hospitals, and is a proper function of hospital boards.