course of every year. Again, each voluntary hospital has to live
by competition, a fact which guarantees that everything in the
way of new treatment and scientific development shall in due
course find its proper place within the walls of such an establishment.
Open as they are to the full inspection of everybody
whose knowledge and presence can promote efficiency, the
voluntary hospitals have shown, especially since the last quarter
of the 19th century, a continuous development and improvement.
Here the patients are treated with invariable kindness
and consideration, as human beings rather than cases, to the
great benefit of the whole human family as represented by the
officials, the patients and the students, with their relations and
friends, the honorary medical officers, hundreds of medical
practitioners and nurses, who receive their medical training
in the hospitals, and the ever-increasing number of governors and
supporters by whose contributions voluntary hospitals live.
The great missionary and social value of the voluntary hospitals
to the whole community cannot be questioned, and they have
been of inestimable value to the churches by inculcating the
higher principles of humanity, while removing the many acerbities
which might otherwise prevail between rich and poor in large
cities.
The voluntary hospitals are attended, however, by certain disadvantages which do not attach to municipal institutions. A municipality which undertakes the provision of hospitals for the entire community is largely able to plan out the urban area, and to provide that each hospital site selected shall not only be suitable for the purpose, but that it shall be so chosen as to contribute to make the whole system of hospital provision easily accessible to all classes who may require its aid. The voluntary hospitals, on the contrary, have grown up without any comprehensive plan of the districts or any real regard to the convenience or necessities of their poorer inhabitants. Voluntary hospital sites were almost invariably selected to suit the convenience of the honorary medical staff and the general convenience of the hospital economy rather than to save the patients and their friends long journeys in search of medical aid. The best of the municipal systems too enables economy to be enforced in the administration by a plan which provides a central office in every town where the number of vacant beds in each hospital is known, so that the average of occupied beds in all the hospitals can be well maintained from an economical point of view. This speedy and ready inter-communication between all hospitals in a great city, which might perfectly well be secured under the voluntary system if the managers could only be brought into active co-operation, prevents delay in the admission of urgent cases, promotes the absence of waste by keeping the average of beds occupied in each establishment high and uniform, and has often proved a real gain to the poor by the diminution in cost to the patients and their friends, who under the best municipal systems can find a hospital within reasonable distance of their home in a large city wherever it may be placed. Another advantage of the municipal system should be that central control makes for economical administration. Unfortunately a close study of this question tends to prove that municipal hospitals for the most part have resulted in a dead monotony of relative inefficiency, often entailing great extravagance in buildings, and accompanied by much waste in many directions. Existing municipal hospital systems are attended by several grave disadvantages. The administration shows a tendency to lag and grow sleepy and inert. The absence of competition, and the freedom from continuous publicity and criticism such as the voluntary hospitals enjoy, make for inefficiency and indifferent work. Rate-supported hospitals, as a rule, are administered by permanent officials who reside in houses usually situated on the hospital sites, and who are paid salaries which attract the younger men, who, once appointed, tend to continue in office for a long period of years. This fixture of tenure is apt to cause a decline in the general interest in the work of the municipal hospital, due mainly to the absence of a continuous criticism from outside, and so the average of efficiency, both in regard to treatment and other important matters, may become lower and lower. Those who have habitually inspected great rate-supported hospitals must have met instances over and over again where a gentleman who has held office for twenty or thirty years has frankly stated that his income is fixed, that his habits have become crystallized, that he finds the work terribly monotonous, and yet, as he hopes ultimately to retire upon a pension, he has felt there was no course open to him but to continue in office, even though he may feel conscientiously that a change would be good for the patients, for the hospital and for himself. Under the voluntary system evils of this kind are seldom or never met with, nor have these latter establishments, within living memory, ever been so conducted as to exhibit the grave scandals which have marred the administration of rate-supported hospitals not only in Great Britain but in other parts of the world. We believe that the more thoroughly the advantages and disadvantages of rate-supported and voluntary hospitals for the care of the sick are weighed and considered, and the more accurate and full the knowledge which is added to the judgment upon which a decision can be based, the more certain will it be that every capable administrator will come to the conclusion that on the whole it is good for the sick and for the whole community that these establishments should, at any rate in Great Britain, be maintained upon the voluntary system. Of course it is essential to have rate-supported hospitals where cases of infectious disease and the poorest of the people who are dependent largely upon the poor-law for their maintenance can be cared for. It is satisfactory to be able to state that of late years the administration of both these types of rate-supported hospitals has greatly improved. The added importance now given all over the country to medical officers of health, and the disposition exhibited, both by parliament and government departments, to make the position of these officers more important and valuable than ever before, have tended largely to improve the administrative efficiency of hospitals for infectious diseases. No doubt the whole community would benefit if residents in every part of the country could be moved to take a personal interest in the infectious hospital in their immediate neighbourhood. Amongst the smaller of these establishments there has been so marked an inefficiency at times as to cause much avoidable suffering. The existence of such inefficiency casts a grave reflection upon the local authorities and others who are responsible for the evils which undoubtedly exist in various places at the present time. Unfortunately knowledge has not yet sufficiently spread to enable the public to overcome its fear and dread of infectious maladies. It is therefore very difficult to induce people to take an active interest in one of these hospitals, but we look forward to the time when, owing to the activity of the medical officers of health who have immediate charge of buildings of this kind, this difficulty may be overcome, when the avoidable dangers and risks and the appalling discomfort which a poor sufferer from a severe infectious disease in a rural district may suddenly have to encounter under existing circumstances, would be rendered impossible.
The poor-law infirmary in large cities, so far as the buildings and equipment are concerned, very often leaves little to desire. Poor-law infirmaries lack, however, the stimulus and the checks and advantages which impartial criticism continuously applied brings to a great voluntary hospital. Such disadvantages might be entirely removed if parliament would decide to throw open every poor-law infirmary for clinical purposes, and to have connected with each such establishment a responsible visiting medical staff, consisting of the best qualified men to be found in the community which each hospital serves. The old prejudice against hospital treatment has disappeared, for the least intelligent members of the population now understand that, when a citizen is sick, there is no place so good as the wards of a well-administered hospital. Looking at the question of hospital provision in Great Britain, and indeed in all countries at the present time, it may be said, that there is everywhere evidence of improvement and development upon the right lines, so that never before in the history of the world has the lot of the sick man or woman been so relatively fortunate and safe as it is in
