HOSPITAL ADMINISTRATION

Evening Star, Issue 19017, 12 August 1925, Page 4

HOSPITAL ADMINISTRATION

PROBLEM OF PRIVATE WARDS REPLY TO B.M.A. The New Zealand Hospital Boards’ Association, through its president (Mr W. Wallace, of Auckland), gives tho following reply to the recommendations of the British Medical Association as to admiumkration of hospitals, and particularly as to private wards;— Tiio Now Zealand branch of tho British Medical Association recently published its recommendations on certain matters of policy in regard to public hospitals. “ It is noted by the published report of those recommendations that the British Medical Association lias been asked for its opinion by the Director-General, lb is conceivable, of course, that tho Director-General should have desired to know tho opinion of the medical profession upon the question of tho medical .staffing of hospitals, a matter that intimately concerns it, but whilst hospital boards welcome suggestions which show an interest in hospital mattors from all concerned, such questions of lay administration as the Bomber 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 bo deemed authoritative. “ For these reasons the views of the British Medical Association on the matter of medical staffing of public hospitals are regarded as forming tho most important feature of its recommendations, and in this connection particularly that comment is made.

“The B.M.A. 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 alforcl far hotter treatment facilities in many respects than are provided in private hospitals. “At a conference of hospital hoards’ delegates at Wellington in October last the principle was affirmed of providing private wards in 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 1 introduction would tend to cause class distinction. I do not think that such would bo the case—class distinction now exists- and will continue to exist until human nature changes. It possibly exists at present in both public hospitals and private 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 agreed to, pay the full cost of maintenance, including a proportion of depreciation charges, interest on capital, and administration expenses, “The full adoption of this policy so far as it is possible is, however, a matter of quite gradual development, depending on the influence of several factors (operating to a variable extent in different districts'), including the allimportant one of finance, the existence of relatively efficient and attractive private hospitals, and also, no doubt, the present question of medical staffing. THE COMMUNITY SYSTEM. “The recommendations of the British Medical Association as regards the medical staffing of public hospitals as i understand them arc, in effect, that: (a) All the medical and surgical work of the hospital shall ho in the hands of medical men in practice in tin’s district under whoso direction, however, the resident medical officers of the institution may bo permitted to act. (b) Patients able to pay medical fees as well as hospital fees, and patients who voluntarily enter private wards should bo required to make arrangements for attendance by a doctor of their own choice, the fee to bo a matter between patients and doctor. „ (c) Patients other than those just referred to arc to bo attended by local practitioners appointed as parttime 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 control ling _ board) shall bo appointed and 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 tho United States, though I believe in connection with only one or two rate supported institutions. “ It would be as well hero to point out that the community hospital, or, as it is otherwise known, the ‘open hospital,’ is by no menus 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. Tho efficiency of the Ford Hospital is as uumistnkeablo as of all that remarkable man’s undertakings. No doubt, ha recognised from tho commencement the absurdity of entering into a contract with a certain section of his employees on such a vague, unsatisfactory, and uubusinwarlike nature as that obtaining in the community (hospital. (Whatever tho nature of their employment and service the medical staff of a hospital are as much the employees of tho institution ns are the nurses, engineers, clerks, or any other employee. STAFFING DIFFICULTIES. “ From the viewpoint of the bulk of the medical profession the proposals may represent an ideal arrangement, but I do not think hospital boards ortho public generally will regard them with favor. In the first place, it has been the experience of some boards that the placing of all the medical and surgical work of the hospital in the hands of the medical men in practice in tho district has not been entirely satisfactory, mainly owing to the lack of disciplinary control and jurisdiction, with the result that these boards have been compelled to appoint full-time stipendiary medical officers, and it has apparently been their experience that this is 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 exorcising control over tho visiting medical stuff. On the contrary, its recommendation is clearly that the work should be in the hands of the medical practitioners entirely. “ Furthermore, oven members or 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 ho distributed over medical practitioners in the district, only a few of whom will naturally have that opportunity. “ In regard to the recommendation that patients deemed able to paj should

bo required to make arrangements fori 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 bo deemed able to pay. From tho viewpoint of the public: it is, moreover, not offering tho reasonable facilities for treatment in our public hospitals that are desired. When tho principles of private wards was affirmed , at a. conference of tho hospital hoards’ I dolomites held in October last it wasi also'agreed that patients in these wards ■ be given tho opportunity of engaging l their own medical advisers, but it was not simnrestcd that any class of person, if in of .hospital treatment, would ho compelled to engage his own medical attendant or should tic denied the services of tho hospital medical staff. Any such suggestion of compulsion or rostne-» tions in regard to a particular class oi | patient does not seem entirely consis-i tout with the desire fo offer tho bene-, fits of treatment in our public hospitals j to the public generally. _ “ If tho policy is adopted of opening | hospitals to all'who seek admission, it i naturally follows that tho medical staff should not be expected to work_therein without remuneration, and the Hospital Hoards’ Association is in agreement with the recommendation that the medical staff should ho paid cither partly or in full for their services. This is on the lines of the suggestion made recently hv the Director-General and approved at a conference of tho Hospital Boards’ Association in Auckland. In this connection, however, 1 note that the British Medical Association recommends that in the case, of smaller hospitals all medical practitioners (except those deemed unsuitable by a proposed i central board) should bo given the right | to attend their own patients in the j public wards if they so desire. No | board with any choice in the matter would accept the principle that all pracititionors in tho district should he per- , miffed to attend their own patients in its institution. Firstly, because it is necessary, particularly as regards I patients in tho public wards, that responsibility for professional medical attendance he definitely fixed and capable of determination. Secondly, treatment methods and ideas of internal economy on tho part of medical men are such | variable quantities that it might mean ; possibly playing fast and loose with tho ratepayers’ money. “In regard to tho suggestion that in > the larger hospitals as far as practicable the whole-time medical superintendents should confine their duties to administration, I mayjmy at once that .1 am strongly and definitely opposed in : such a proposal. Why should a highiy- ■ qualified and efficient medical man ho relegated to mere routine duties? What is tho use of his clinical training and experience if he is not to ho allowed to avail himself thereof, and what would he his future? A considerable amount of explanation of this clause of the profession’s policy is required before a considered opinion can he expressed thereon.-but, generally speaking, there can ho but one professional head ol 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,'hut this is by no means tho case in many of onr other hirger hospitals. As a matter of fact, in so far as the hoards’ medical officers exercise no jurisdiction or control over the various part-time medical officers, thorn exists a fundamental defect, and it has been for this reason chiellv that some hoards have been compelled to dispense wilh the honorary stuff and substitute lulltime officers,” SUMMARY OF POLICY.

Having dealt at length with tho proposals of the other matters in regard In medical stalling, it would be as well to summarise the recommendations of tho executive of the Hospital Boards’ 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 bods, and all that the medical practitioners should be concerned with is whether the physical condition of the patient is such as to make him a fit subject for hospital treatment ami whether he would benefit thereby.

2. That the principle is affirmed of providing private wards in public hospitals, patients voluntarily entering such wards to bo at liberty to engage their own medical advisors. 3. The institution of private wards is a matter that should be Iclt to each hospital hoard, as also tho question as to whether the board should permit patients admitted to these private wards to obtain the services of the board’s full-time medical officers in lieu of an outside practitioner. Where permission is not granted the hoard should preserve flic right to approve a scale oi fees that'may bo charged by outside practitioners. 4. That the honorary staff cannot he expected to givo their services free, and should ho remunerated.

r>. That in no public wards should patients ho attended by other than the medical staff appointed by the board. (i. That fees charged in the case, of patients admitted to tho public wards should for the present bo not raised to more than (Is per diem for adults, with reductions for children. Patients admitted to private wards should he 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 nil other matters of internal administration of tho hospitals tho executive is generally in accord with the model by-laws issued by the department.

8. There should he 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 bo triennial (instead of biennial) as in tho 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, ancl the treatment of the indigent sick in public hospitals, and is a proper function of hospital hoards.