HOSPITAL REFORM.

New Zealand Herald, Volume LXIX, Issue 21110, 18 February 1932, Page 11

HOSPITAL REFORM.

NEED FOR CONCENTRATION; IMPROVEMENT IN SERVICE, UNNECESSARY INSTITUTIONS. HIGH ADMINISTRATIVE COSTS. BY R. CAMPBELL BEGG. Previous articles have dealt with the benefits to be gained in the treatment of sickness and the preservation of national health by concentrating our hospital system under 18 board administrations co-ordinated by a central advisory board of hospitals. The benefits to the national exchequer would be no less striking.

To give point to the question of reduction in expenditure it will bo useful to consider a priori the question of hospital provision in relation to population in general. Tho conference on rural hygiene under the auspices of the League of Nations, held last year, decided that two beds per thousand of population was a reasonable standard. Of the population of the Dominion about one-fifth is catered for in private hospitals, leaving 1,280,000 dependent on public hospital facilities. At the rate of two beds per thousand (International Geneva Conference scale) this would necessitate tlie provision of 2560 beds, which at a maintenance rate of £l5O per established bed —a very liberal allowance—would result in an expenditure of £384,000.

The actual cost of maintenance, after deducting charitable aid costs, was, in the year 1930-31, £1,592.670. The total burden on the public funds (rates and taxes) in the year 1913-14 amounted to £279,000. Adjusting this for increase in population, wages, and cost of provisions, the expected burden in the year 1930-31 would be £497.000. The actual figure was nearly £1,300.000. Expenditure Out of Control.

There are many factors which may rightly be brought forward to account for increase in expenditure, such as more lavish j/.-ovision of beds for chronic cases, infectious diseases, including tuberculosis; maternity cases, and the like, as well as increased nursing and ambulance service to outlying districts, but it is beyond the bounds of credibility that these enormous discrepancies (£1,200.000 and £BOO,OOO respectively) can be attributed to justifiable ex]>ansion, or that they are reflected in corresponding improvement in the scope and quality of the medical benefits conferred. The simple fact is that the half-million spent in the year 1913-14 was open to criticism, and the same service could at that time have been obtained much more cheaply if the hospital districts had been fewer and more co-ordinated. What shall we say of the Pelion of £BOO,OOO piled since then on the Ossa of the pre-war year ?

No appeal to increased cost of hospital equipment and complexity of medical service can stand in the face of such figures. The simple fact is that hospital expenditure lias got out of all control, and efficiency and co-ordination have suffered in the same ratio as costs have increased, and from ths same cause. Storey upon storey has been added to the building, while the foundations have neither been strengthened nor extended. The reverse process, a much more difficult architectural problem, must be set in train at once if the crazy building is to continue to stand. The only alternative is to demolish it and erect a new edifice in its place. High Costs Per Bed. It is proposed that this rebuilding should develop around 18 base hospitals, standardised and co-ordinated by the Department of Healt.h, strengthened for the purpose by the formation of a central board of hospitals. Only in this way can the system gain cohesion. The expenditure would diminish at once and. along the following lines: — 1. Reduction in Administration Costs Apart from Medical Administration.— The 27 boards to be absorbed cost some £20.000 under this >:ead last year. An analysis of the expenditure of the remainder shows that not only would the costs not go up owing to the larger districts involved, but. that they could be diminished by careful overhaul and the standardisation which the new system would make possible. 2. Elimination of Unnecessary Hospitals.—The Geneva Conference on Rural Hygiene mentioned above laid down that any hospital under 50 beds was an uneconomical proposition. A study of New Zealand hospitals will amply support the proposition. There are in New Zealand 58 hospitals with an average of less than 10 occupied beds per day. Twenty-four of these are general and 34 are maternity. Forty-one average less than five occupied beds, and 15 less than two. There are cases where there is an average of four staff to each occupied bed. In some of these there, is a very high average stay per patient. In one instance as high as 40.9 days. The cost of these 58 hospitals, in provisions, equipment and staff, apart from any other expense, is £78,482. Twenty-seven of them average in maintenance over £3OO per occupied bed. 17 over £4OO, four over £SOO, and one hospital the amazing total of £623 16s Bd, or a fraction of a penny under £l2 a week. If the latter institution were a private one, and interest on first cost, depreciation, insurance, rates and tax were added the cost per patient per week would be £ls.

Standardising Base Hospital;. An ambulance would serve many of the districts concerned better than a hospital and its total upkeep, depreciation, and driving charges, and storage in the hands of a local garage would probably not total more than £59 instead of the two or three thousand pounds being paid at present. Many, if not most, of these hospitals could be closed down without detriment, and in some instances, with advantage to the patients and the district. 3. Reducing Hospitals to Secondary or Cottage Status. —A large number of hospitals at present doing the work of base hospitals, or at least equipped as such, with the consequent heavy overhead, could send all but their acute and simple cases to the base hospital, and treat the others effectively with a minimum of equipment and staff. Trained nurses, district or Plunket, overlap in many districts, and their services could bo brought into use in connection with these hospitals. 4. Standardising of Base Hospitals.— Thorough overhaul and uniformity of plan would result in very considerable savings in base hospitals themselves, and they would run at considerably less expenditure even while catering for their enlarged districts. At present every hospital is more or less a law to itself subject to periodical but very occasional thorough overhaul by officers of the Health Department-. These inspections result in changes being made with great diminution of expenditure in many instances. Standardisation of methods would prevent this expenditure being incurred. The recommendations of the Health Department savour of shutting tha stable door after the horse has left, and even then many boards refuse to shut it, e\%n for the purpose of conserving such horses as are still in residence. * In addition to what has been mentioned, colossal savings could bo made by co-operative buying, and by better teamwork leading to shorter stay of patients. Headquarters' administration would r.p> less costly, as the system to be supervised would be more uniform and closely knit* The chango must come. It promise! efficient service, half-a-million less expended each year, and 33 out of every 100 pounds saved to each ratepayer.