contrary, another aspect of the problem of equal if not greater
importance is the question of hospital expenditure. In times past,
when hospitals received from the subscribing public whatever income
they chose to appeal for, there was not that incentive to exercise
scientific check and control over expenditure that became urgent
when income was so much more difficult to collect. This subject of
hospital expenditure is pregnant with great possibilities for economy,
provided there could be established the necessary supervising
authority to carry out the investigations and the consequent recom-
mendations. Intimate knowledge of both military and civil hospitals
reveals one point of marked difference between the two types, greatly
to the financial advantage of the former, namely a coordinating
uthority. In the British military hospitals a system of comparative
returns " was instituted by the army medical department dealing ith such items of expenditure as food, drugs and surgical dressings, laundry, personnel, etc. These "returns" were of two kinds: (a) intra-hospital, comparing ward with ward; and (6) inter-hospital, comparing individual hospitals with each other. The circulation of these " returns " exercised a silent pressure which resulted in an enormous reduction in expenditure. The good points of any one hospital were soon brought out in the circulating returns and became apparent for other hospitals to emulate. No such inter-hospital comparison existed amongst the voluntary hospitals: each hospital was an isolated unit, with little regard to any other hospital and learning few of the good points from its neighbours. It would be almost futile to set up any basis for stabilizing the financial position of hospitals without the necessary corollary of establishing some system of coordination. Hospitals themselves admit the necessity for something of the kind to be established, but so long as the spirit of individualism prevails there can be small prospect of any system of coordination being set up from within the hospitals themselves. It must be instituted by some body outside the hospitals having the power to render monetary assistance to the hospital. In the absence of coordination amongst the hospitals it is a fair deduction to say that the money subscribed by the public is not put to its best use, for there is not only considerable overlapping on the part of the hospitals in purchasing commodities hospitals competing against one another in the same market, sometimes in the same town but there is also overlapping of hospital accommodation.
In some parts of England there are more hospital beds than are required, while in other areas there are large waiting lists of patients which the hospitals are not overtaking. No one in 1921 had any authority to exercise influence over the hospitals so as to come to some arrangement by which the smaller hospitals might bring relief to the big hospitals by taking over some of the patients who suffer from less severe ailments. The large general hospitals are neces- sarily expensive institutions because of the special equipment and staff required, and when these hospitals become full and waiting lists develop, the hospital committees usually begin to think of means to extend their accommodation, or, in other words, to enlarge ihe inlet into the hospital; whereas a more practicable policy would be to evacuate their patients more rapidly into auxiliary institutions, such as the cottage hospitals in the surrounding country in other words to enlarge their exit. Further, there is urgent need for some scientific scheme of training for hospital administrators. The standard of administration in 1921 varied within wide limits in the voluntary hospitals. The only experience some of the existing administrators had had was in office under the superintendence of their predecessor, and therefore they were apt to be content to attain to the standards of the past. Hospital administration has become an increasingly complex science, due partly to the ever-increasing specialization of the various departments. It is widely recognized that a carefully selected course of training is required for a woman to become an efficient almoner; so also the hospital treasurer has to be scientifically trained in the various branches of accountancy. But for the more responsible office of hospital administrator no special standard of training seems to be expected, nor isspecial training available.
A hospital is much more complex than most business organizations of equivalent size. Its peculiarity is the inclusion of a number of different professions, each highly specialized, which must work together and which roust be kept in effective working relations. The basis of a hospital is its medical staff, but in addition to this medical element is the business administration represented by the superintendent and his administrative assistants. The nurses form another highly specialized and well-organized group. Social service (hospital almoners) represent still another and different type of work in the hospital; and there are, finally, the housekeeping, mechanical and clerical groups, who maintain the essential daily routine of the hospital. It should be added that while the emphasis of the work of most superintendents is on the business side, the superintendent ought to interpret, develop and represent all phases of a hospital's activity. Hospital personnel thus includes such widely varying elements and draws them into such intimate relation- ship that the successful organization and administration of a modern hospital is a difficult matter requiring special training and skill.
In America this problem of the training and equipment of hospital administrators has also been experienced, and a committee has been established, under the auspices of the Rockefeller Foundation, to report upon " the need and practicability of inaugurating a course of training for hospital executives."
Available Bed Accommodation. "Hospitals represent, or ought to represent, the organization of medical services upon a scientific basis, bringing to bear upon the needs of the individual patient the maximum resources in equipment and skill that 20th-century medical science can muster. To promote a better understanding of hospitals by the community is to promote at the same time their better and more discriminating utilization and their more effective and generous support." This quotation from the Cleveland Hos- pitals Survey briefly expresses the ideal service that hospitals offer to the community. The British public have become educated during recent years to appreciate the valuable medical and surgical services now provided in general and special hospitals, hence the ever-increasing demands made by patients seeking to avail them- selves of the best that medical science can give. These scientific developments within the hospitals, on the one hand, and the appre- ciation of them by the public on the other, disclosed a situation that called for investigation and reform namely, the failure of hospital accommodation to keep pace with the demands. At the beginning of the 2Oth century the generally accepted hospital bed rate was one bed per 1,000 population, but that ratio was no longer maintained in 1921, for, as in the case of general housing of the people so with the housing of the sick in hospital, the supply of hospital accommo- dation had fallen in arrears in many districts since the time at which the hospitals were erected. The number of hospitals that can show " waiting " lists of patients seeking admission is too large for this aspect of the hospital problem to be ignored. Many hospitals have of recent years become so accustomed to the waiting-list problem that we are liable to overlook the fact that such lists imply a con- siderable amount of preventable human suffering, especially in the case of patients with haemorrhoids and hernia, and yet these dis- eases are responsible for the majority of the names on a waiting list. Further, some hospitals keep no record of the number of cases that have been refused admission owing to lack of accommodation. A hospital committee of management ought to be furnished each month by its superintendent or officer in charge with a statement showing the number, sex and age of each applicant for hospital accommodation that was refused admission and the reasons for the rejection. Such a procedure would educate those responsible for the good government of the voluntary hospitals to appreciate to what extent their institution was meeting the needs of the community.
But it is not only in regard to accommodation for patients in hospital that consideration is required, but also in regard to the accommodation for staff. With the reduction of nurses' hours on duty and consequently the increased number who have to be employed to overtake the work of the hospital, many hospitals have found their accommodation for staff inadequate. This was in 1921 one of the most pressing problems before many hospitals.
Hospital accommodation, whether for patients or staff, is obviously closely dependent on finance, and the financial position of these hospitals in 1921 was such as to put hospital extension entirely out of the question. In the London group of hospitals these financial difficulties regarding capital expenditure on increased accommoda- tion were being experienced, as elsewhere. In the interim report by the Policy Committee of King Edward's Hospital Fund for London, dated April 12 1921, referring to increase of hospital accommodation, the following statement occurs:
" In spite of the large sums already subscribed by the public, it is evident that the financial problem of making provision for even the most urgent development of hospital accommodation is a serious one; and the possibility of saving capital expenditure by making use of any existing buildings, whether at present under voluntary management or not, requires the fullest consideration, including, for example, the question of homes of recovery and the question of unused beds in Poor-Law infirmaries."
Hospital Standards. No investigation of the hospital problem would be complete without some reference to the question of hos- pital standards. Any reference to standardization in connexion with hospital work is apt to convey, to those who are satisfied with a superficial view, the suggestion that this implies interference with initiative and the substitution of mechanical limitations.
On the contrary, some voluntary hospitals fail to function to their highest capacity because of the absence of definitely accepted standards. When a minimum standard of efficiency is defined, below which no hospital should be allowed to fall, there is no implication that any hospital should rest content on this minimum line; but the public have a right to expect that some accepted standard is main- tained. Necessity exists for a generally accepted hospital standard in regard to two subjects namely, hospital accounting and the training and equipping of hospital superintendents. In respect of the former some standard of uniformity is required before hospitals can be adequately compared with one another. This does not necessarily imply interference in any individual hospital with the system of book-keeping that may have been evolved to meet local requirements, but in addition to that the hospital should, for the purpose of an inter-hospital comparison, conform to some uniform system of accounts. Again, it has been pointed out how essential it is that some standard of efficiency in training should be expected from any applicant for the post of hospital administrator.
Nurses' Training. Another hospital service that requires a minimum standard to be fixed is that of nursing, both as regards
