The hospital system has grown from many roots and is therefore of a very diverse nature. The division between voluntary and public hospitals is largely a matter of their constitution. Voluntary hospitals are institu- tions responsible only to themselves, while public hospitals are under the control of local authorities who in turn are responsible to an electorate. Public hospitals therefore are maintained mainly out of taxation, while voluntary hospitals must finance themselves.
The earliest charitable institutions in England were houses of hospitality regarded as a religious obligation. Hospitals for indigent persons were founded in the tenth century. In 1170 pilgrimages to the shrine of St. Thomas of Canterbury led to the foundation of another type. In the fourteenth century yet another kind of hospital was established for vagrant paupers and the sick poor. Alongside of this slow growth were the almshouses, the lazar houses, and the refuges for the insane which were being established. Other hospitals were built in the eighteenth century by rich citizens proud of their towns. Most hospitals, however, were built to meet the needs more especially of the populations which had flowed into the towns during the Industrial Revolution.
At the time the National Health Service Act came into operation there were about 1000 voluntary hospitals in Great Britain with about 80,000 beds. Except for the British Post-Graduate Medical School at Hammersmith, each medical school was associated with a large voluntary hospital.
Although the income from charitable sources had been rising, it had not kept pace with the increasing expenditure, so the voluntary hospitals were obliged to devise means of raising funds. Contributions were invited first from those attending out-patient departments, and later from in-patients. Approved Societies were urged to include hospital treatment in their additional benefits, and some granted to hospitals donations out of their surpluses. Local authorities paid hospitals for the work they did for them, and many authorities took advantage of their powers to make direct grants from the rates. The most successful of the ways of raising money, however, was the creation of hospital contributory schemes. The Hospital Saturday Fund had been founded before 1914. Others developed after 1918, mostly between the years 1929 and 1934. Most of the schemes restricted their membership to those of the lower income limits. For their contributions subscribers received free treatment in the voluntary hospitals. A number received additional benefits such as convalescent treatment, ophthalmic treatment, dental treatment, district nursing, maternity allowances, etc.
Some of these contributory schemes applied only to certain limited localities, e.g., the Birmingham Hospital Contributory Fund. Others such as the L.M.S. Railway Hospital Fund were limited to certain sections of the population. The very success of these schemes had for long raised the question of whether, rather than voluntary contributions being made by a very large section of the community, the hospitals should not be financed out of the rates or be state maintained. Hospital services had not been brought into the insurance schemes as one of the benefits, either because it would not have been financially possible, or because there were not sufficient beds to ensure that accommodation could be found for all those who on this basis would have been entitled to admission as a right. To meet the needs of the growing number of middle-class people who could not afford to be admitted to private nursing homes and to pay the full fees of the specialists, most voluntary hospitals made provision for the admission of private and paying patients. T h e Voluntary Hospitals (Paying Patients) Act of 1936 empowered the Charity Commissioners to authorize the provision of such beds in hospitals where the terms of the trust had hitherto prevented them. In addition there were schemes for private hospital treatment for middle-class patients, most of them being attached to particular hospitals.
Most of the public hospitals were built in the nineteenth century as Poor-Law Hospitals or as infectious diseases hospitals. Since 1875 local sanitary authorities have had the power to provide general hospitals out of the rates, but in only three instances up to 1930 had this power been exercised. The Boards of Guardians were obliged to make provision for the destitute sick in general hospitals or other institutions. Many of these were by 1930 being used by the public as hospitals for the general sick, although technically every patient admitted was a pauper. This was because of lack of other hospital accommodation, coupled with the growing demand of the public for hospital facilities.
The 1929 Local Government Act transferred the powers and duties of the Guardians to the Public Assistance Com- mittees of the county and the county borough councils. These authorities were given powers to appropriate the former Poor-Law Hospitals to make them public hospitals, or alternatively to build general public hospitals. Public hospitals contained three-quarters of the total number of available beds, including nearly all those for infectious cases, most of those for tuberculosis and maternity, while most chronic cases sent into hospital were admitted to the public hospitals.
Until recently local authorities had no specific powers to provide out-patient treatment. This position was regularized by the 1936 Act since when public hospitals in general have provided this service.
The haphazard growth of the hospital service has resulted in some areas being practically devoid of beds while others have more than their strict needs. It was not until the 1929 Local Government Act that any machinery existed for ensur- ing that new accommodation was to be provided in accordance with any plan. While much of the new accommodation is being provided by public hospitals, the needs of an area cannot be controlled by local government boundaries ; nor should this service be considered in terms of either public or voluntary hospitals. T h e new hospital areas, at least for purposes of planning even if not for administration, had to be large, with their general pattern having regard to modern conditions of transport. It was with this background that the proposals for the hospital service under the National Health Service Act were framed, the distinction between voluntary and public hospitals being abolished, and the hospitals grouped into 14 regions which ignored local government boundaries.
In the country as a whole there are about 7 hospital beds for all purposes per 1000 population. In 1938 admissions to hospitals for the general sick were about 20 per 1000 population.
Most patients admitted to hospital do not need the full services available at a hospital up to the time they are discharged ; but, needing more than they can obtain at home, in default of any other accommodation they have to be kept at the hospital. Pressure on hospital beds makes the provision of convalescent homes a measure of economy, as the patient can be freed from the hospital that much earlier, while at the same time can be detained longer than he possibly could be at the parent hospital. Another advantage of associating a convalescent home with a hospital is that the home can be in better surroundings than the hospital which has been sited to meet the needs of a town. Although there are these advantages in such an arrangement, in fact only a small proportion of convalescent home accom- modation has been provided by the hospital authorities.
Private enterprise was responsible for the first of these homes. The next development was provision by trades unions and co-operative societies ; and then local authorities and employers of labour provided homes. Even to-day, however, most of the approximately 500 homes in this country are run by private effort.
The provision of convalescent homes should be brought into association not only with the hospitals but with ordinary domiciliary medical services for those who do not need to be admitted to hospital. Many of those recently treated in hospital need occupational and recreational therapy to restore them to complete recovery. Similar provision should be made for those who if the service were available would perhaps not reach the stage of requiring hospital treatment. To bring about the necessary co-ordination and to ensure that patients are admitted, not merely to a convalescent home, but to that which is best suited because of equipment, staffing, or localization to their needs, will necessitate a central or at least a regional organization.
While most parts of the country have been covered by an ambulance service, this was provided by a variety of bodies. Most large towns maintained their own ambulance service which provided not only for the removal to hospital of accident cases, but of ordinary patients including maternity cases from their own homes to hospitals. In many parts of the country this work was undertaken by the county organizations of the Order of St. John of Jerusalem and of the British Red Cross Society. In some districts removal of accident cases was arranged by police ambulances. A number of general hospitals had ambulances, while most infectious diseases hospitals had their own vehicles which were reserved for the transport of infectious cases. Under the National Health Service Act every local health authority is required to secure that ambulances and other means of transport are available where necessary for the conveyance of persons suffering from illness or mental derangement, or expectant or nursing mothers. They may carry out this duty by themselves providing the service or by making arrangements with voluntary organizations, or other persons.