Hospitals

"HOSPITALS 13.791). -

Great Britain

. - During 1910-20, and especially late in that decade, the problem of voluntary hospitals became gradually more acute. Considerable confusion had arisen in the minds of many people by 1921 as to the relative value of the various remedies that had periodically been suggested. Some of these suggested remedies had not received general approval because they failed to meet the situation as a whole; some were obviously devised to meet the pressing needs of an individual hospital heedless of the effect on other similar institutions, while other so-called cures were but attempts to remove some individual symptom. In other words, treatment has often been prescribed prior to the diagnosis of the disease. In order adequately to appreciate in broad outline the hospital problem as it presented itself in 1921 in Great Britain, it is necessary to consider its various aspects.

The Principle of Management

There are three ways in which British general hospitals can be managed: they may be (a) controlled by the State; (b) controlled by the local municipality (county or borough councils); or (c) continued on the so-called voluntary basis, as at present.

The advocates of a State hospital service occasionally cite the excellent attainments of the military hospitals during the World War in support of their argument; but it should be pointed out that, although such hospitals were State institutions in so far as they were staffed and financed by the State, their success was in no small measure contributed to by the great volume of voluntary aid supplied in the form of personal service at the central hospitals as well as in the auxiliary institutions, which proved such a valuable adjunct to the military hospital system. The question of municipal control of the general hospitals of the country was discussed in Parliament and in the public press in 1920 in connexion with the Miscellaneous Provisions of Health Bill introduced by the Minister of Health, with the result that it soon became apparent how widespread was the opposition to the possibility of any such contingency. The opposition appeared to crystallize round the idea that the general hospitals would thus be brought into close proximity to, and therefore likely to be influenced by, the fluctuating tides of local politics. With possibly a preponderating vote for Labour in one area, and in another the controlling vote in favour of a policy for the reduction of local rates, the obvious result would be a disparity in the amount of hospital provision and in efficiency of management even greater than exists at present throughout the country. In the bill referred to, as originally introduced, the Minister of Health asked Parliament for powers to enable the county and borough councils (I) to supply and maintain hospitals, including out-patients' departments for the treatment of illnesses; (2) to contribute on such terms and conditions as the Minister may approve to any voluntary hospital or similar institution within their area. The Minister of Health repeatedly announced his desire to maintain the voluntary hospitals on their existing basis, but in asking for such wide powers in his bill he roused the opposition of many who read more into the bill than the minister really intended.

Although the bill never reached the Statute Book, it will doubtless be regarded by the hospital historian as having been the means of the voluntary hospital system making a real step forward, for out of the discussion on the bill came the establishment of the committee presided over by Visct. Cave, a body appointed by the Minister of Health " to consider the present financial position of voluntary hospitals and to make recommendations as to any action which should be taken to assist them." The appointment of this committee met with widespread approval, for all genuinely interested in British hospitals realize that the first essential step prior to any legislation is to investigate the evidence from the country as a whole and thus ascertain the existing " facts " from which to evolve some solution of the present problem. The Cave Committee was appointed on Jan. 25 1921, and on March 9 an interim report was published which contains the following important announcement: " The evidence already received has convinced us that it is desirable in the public interest to maintain the voluntary system of hospital management." Such an important pronouncement by a body of independent investigators could hardly fail to exercise considerable influence in stabilizing public opinion and to encourage that large body who by their voluntary contributions have hitherto been the mainstay of a hospital system which is regarded as unique in the history of charitable institutions. The Cave Committee recommended that a State grant of £1,000,000 should be made in relief of hospital finance, but in June 1921 the Government decided to make this only £50o,000, the condition being that further voluntary effort should he made in order to keep the hospitals on an independent basis.

Hospital Finance

Whoever seeks to investigate this aspect of the British hospital problem as a whole quickly encounters difficulties which may well appear almost insuperable. King Edward's Hospital Fund for London makes it conditional for any hospital applying for a grant that the uniform system of accounts be used, with the result that it is a comparatively simple problem to obtain a clear statement of the finances of any individual hospital, or of the group as a whole, in the London area which comes under the supervision of the King's Fund. But there is no supervising authority for the hospitals outside London, with the result that in the provinces, in Scotland and in Ireland the voluntary hospitals adopt a bewildering variety of forms for presentation of their financial accounts. This lack of uniformity makes it exceedingly difficult to ascertain the real financial position of many individual hospitals, and almost impossible to institute a reliable basis of comparison for the hospitals in the aggregate. Owing to the absence of a uniform system of hospital accounting, the annual hospital report is of little value for comparative purposes. The annual report as at present constituted is a production for " home consumption," that is, for the individual hospital committee, and is useful in comparing the costs of one year with another, but is of comparatively little value for the purposes of an inter-hospital comparison, and unless hospitals are in a position to compare themselves with similar institutions, they are apt to remain isolated units without the privilege of learning from the good points of their neighbours.

A reform urgently needed, not only for the provincial hospitals but also for those under the supervision of the King's Fund, is some simplified system for showing a hospital's financial situation, so that the subscribing public might readily understand the position of the institution they are asked to support. It is no longer enough for a hospital secretary to publish the bald statement on the front page of the annual report that such and such a sum of money is urgently needed to keep the hospital going. A hospital financial statement should set forth the total amount of money received during the year from all sources, from individual sources, and details of what has been done with the money received.

Prior to and during the World War the voluntary hospitals as a general rule experienced no great difficulty in obtaining financial support sufficient to meet their expenditure. Voluntary subscriptions and donations constituted the major portion of the receipts. Certainly during the years 1915-8 inclusive, when so many hospital beds were occupied by patients paid for on a capitation basis by the State, the majority of hospitals were able to show an ever-expanding income. But when this financial prop was removed during 1919 hospitals were caught unprepared.

When the military patients disappeared their places were speedily taken by non-paying patients. Hospitals had recourse to their old pre-war method of raising money, namely the spasmodic public appeal, only to find that such methods no longer possessed the necessary power of earlier days. The result was that hospital secretaries appealed through the public press for the support necessary to stave off the threatening financial disaster. But during this period, while so many were declaring their helplessness, several hospital secretaries took stock of the new conditions, realizing, amongst other facts, that the possession of money, as a result of the war, was more widespread amongst the community. They appreciated the fact that their hospital patients were drawn from a class of the community who were now, and had been during the war, in receipt of much higher wages than formerly, and to these employees in factories and workshops the hospital secretaries appealed for weekly contributions and organized the necessary machinery for collection. This source of revenue has proved most profitable to many hospitals, but unfortunately there are some hospital secretaries who appear reluctant to explore this source of wealth that is so ready to their hand.

In 1919, a period before workmen's contributions had been generally adopted by the hospitals, it was found that, out of 600 hospitals (in the provinces) investigated, 374 showed contributions from employees amounting in the aggregate to £518,043, or approximately 20% of their ordinary income.

Again, many hospitals realized that there were those amongst their in-patients who were no longer content to place a small coin in the hospital poor-box in gratitude for the services received, but who now desired to pay a more substantial contribution towards their expenses, so that in 1921 the majority of the hospitals had in operation one of three possible methods by which patients' payments are made: - (a) Many hospitals had adopted the almoner system, that is, specially appointed hospital employees who approach the individual patient who comes to hospital, explain the needs of the hospital, and invite the patient to contribute according to his ability. (b) A few hospitals had adopted the less popular plan of instituting a fixed daily or weekly levy from their patients on account of maintenance. (c) Comparatively few hospitals in 1921 were without the reserve of a small number of beds for patients who desired to pay the cost of their maintenance. Many of the small or cottage hospitals in the provinces had instituted the system of paying-patients some years before, but there were still some of the larger type of hospitals that had made no such arrangements. The London hospitals were quickly adopting some system of patients' payments, as shown by the following figures. In 1913 the amount obtained from payments made by or for patients was £78,000. In 1919 it was £124,000 - an increase in the six years of £46,000 - whereas in 1920 the total from this one source reached £230,000; and if patients' donations are included the total reached was £260,000 - an increase of £182,000 in the seven-year period. In the provinces in 1919, 600 hospitals with 33,514 available beds showed a total ordinary income, including un-earmarked legacies, of £3,486,098. Payments made by or on behalf of patients amounted to £803,741, or 23% of the total ordinary income. It has to be pointed out that these figures being for 1919 include some figures that may be regarded as non-recurrentnamely, capitation payments for the military patients who were then remaining in hospital. The question of " paying-patients " in voluntary hospitals was repeatedly urged by that great hospital authority the late Sir Henry Burdett, who pleaded with the hospitals to adopt the principle not only as a relief to hospital finance but as broadening the basis of usefulness to the community.

The following figures, supplied by the Cleveland Hospitals Survey are from three large American general hospitals and show the ratio of paying to non-paying patients: - Of the various other possible sources of hospital income in England there is one that calls for special comment - namely, payment on behalf of National Insurance patients. The section of the National Insurance Act dealing with medical benefit does not make provision for the payment of hospital treatment. The operation of the Act has thrown an unexpected volume of work upon the voluntary hos pitals, both in the in-patient and out-patient departments. This fact, with all the expense involved to the hospitals, was rather obscured during the six years of the war period because of the necessary pressure in making provision for the treatment of military patients and also because hospitals were in receipt of enhanced incomes from the War Office; but after these conditions had disappeared the hospitals realized the great pressure that the operation of this Act placed on their finances. Medical men who act as panel practitioners continued to recommend their panel patients to the hospitals in increasing numbers and for these the hospitals received no direct payment. Hospitals had some claim for financial consideration for the treatment of patients under the National Insurance Act. Such payment should not take the form of a capitation rate, as such rates would inevitably tend to rise and have the effect of drying up income from voluntary sources and also probably in time necessitate some degree of State control over the hospitals on behalf of the approved societies. Any payment for insured patients might rather take the form of block grants to hospitals, administered through a central hospitals board, after careful assessment of the general work of the hospitals, especially in regard to the standard of service and also of the efficiency of administration.

In discussing the disposal of the accumulated surplus, estimated at approximately £7,000,000, Lord Cave's Committee in their interim report made the following statement: " We are strongly of opinion that, in the interests both of the hospitals and of the societies, the schemes to be approved should provide for the application of a substantial part of the disposable surplus in providing a contribution towards the cost of the maintenance of members in hospitals." Hospital Expenditure. - Too often the superficial view is taken that what is known as " the hospital problem " is merely a consideration of finding the additional income that is required. On the 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 recommendations. 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 authority. In the British military hospitals a system of comparative " returns " was instituted by the army medical department dealing with 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 (b) 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 necessarily 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 the 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 is special 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 must 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 relationship 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 Hospitals 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 themselves of the best that medical science can give. These scientific developments within the hospitals, on the one hand, and the appreciation 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 20th 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 accommodation 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 considerable amount of preventable human suffering, especially in the case of patients with haemorrhoids and hernia, and yet these diseases 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, arid 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 accommodation 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 hospital 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 maintained. 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 training of the individual nurse and also the ratio of nursing personnel to hospital beds. A general hospital with a minimum of 50 beds may be sanctioned as an authorized school of training for nurses with permission to grant to the successful candidate a certificate of proficiency. It is well known that the standard of hospital training of a nurse varies widely in different hospitals, depending very largely on the requirements of the individual matron. In some hospitals the standard required of the nurse is very high; it may be even too high, calling for the comment from competent judges that a nurse's training should be restricted to nursing matters and not trespass into the domain of the medical man; while in other hospitals the standard of training is very much lower. Both sets of nurses " qualify " and issue from their respective training schools into the service of the public, each possessing her certificate of proficiency. The public have no means of judging as to the quality of the training of the nurses they seek to employ beyond the general label that " she is a certificated nurse." The probationer nurses receive technical lectures from the matron and her senior assistants and from members of the junior medical staff of the hospital. Unfortunately there are too many hospitals to -day where the same individuals who give the tuition constitute the examining body, whereas in the larger hospitals one or more " external " examiners are appointed to share in the examination of the candidates. It is surely obvious that in such an important profession as nursing there might have been evolved ere this some definite minimum standard of proficiency applicable to all training schools. Again, it is not suggested that hospitals be asked to conform to some rigid mould of training, but in the interest of nurses themselves, and especially of the general public, some minimum standard should be fixed below which no hospital should fall.

A parallel illustration might be quoted in the final examination of the medical student, for it was only after the General Medical Council instituted a system of inspection of the various " final " examinations held throughout the country that something approaching a minimum standard of proficiency was adopted. Further, in regard to the ratio of nurses to beds, hospitals show a considerable range of difference, even after making due allowance for the variety in architectural structure of the buildings. The absence of any standard in this connexion makes it very difficult to institute a comparison between similar hospitals and renders of little value the figure quoted by hospitals as being the " cost per bed," for it is obvious that if one hospital employs more staff than its neighbours, the cost of provisions consumed by them but attributed to the patients will be higher, and so also with salaries and wages.

In conclusion, it may be stated that there is practically no department in a general hospital where some basis could not be arrived at for instituting standards of efficiency. Such standards would be of considerable value to the hospitals themselves and also to the general public, both in regard to economical administration and in the general service to the community; but owing to the want of knowledge of each other, hospitals at present lack the information that would be of so great value in the establishment of standards. This knowledge would readily be forthcoming under a system of hospital coordination, and the institution of some such system seems the most essential step towards a solution of the present-day hospital problem. (N. B.) United States The hospitals of the United States in the years 1910-21 grew in number and made progress in the acquirement of national characteristics and fixed economic and social importance. In 1921 there were in the United States 7,667 hospitals maintaining 695,698 beds; in addition 24,394 beds were used for hospital purposes in homes for aged and in similar institutions. Table I. presents an analysis of these hospitals.

Table L U.S. Hospitals.

Public: supported Private: supported by earnings, by taxation. endowments and contributions.

Federal, State, County, Municipal. ? The proprietary. hospitals show a much larger proportion of the total number of hospitals than of the total number of hospital beds, as most proprietary institutions have less than thirty beds. Larger proprietary institutions are divided into two classes. Some are jointly owned by two or more physicians or surgeons who combine to gain the increased facilities and efficiency obtained by pooling the volume of their professional business. Others are controlled by specialists corresponding to the departments of a general hospital-including X-ray and all forms of laboratory work. This was a recent development and the number of such hospitals was in 1921 few, but they showed great efficiency. The numbers will increase and in 1921 there was evidence that the basic idea-commonly called " group practice " -was bettering the professional service in other hospitals.

The hospitals in 1921 were classified by capacity as follows: Bed Capacity Hospitals Percentage Under 25.3,110 40 56 25 to 49 1,859 24.24 50 to 99 1,263 16.47 100 to 1 99 781 10.19 200 to 499 4055.28 500 to 999 116 1 52 1,000 and over 1 33 1 74 7,667 too oo In discussing the number of active hospital beds (exclusive of convalescent and allied institutions and hospitals for nervous or mental diseases) needed by a given population, the figures for [[Table Ii]].-Hospitals and Active Hospital Beds by States, and Ratio of Beds to Population. Boston and for Massachusetts usually are cited as standard for a city and a state, New York's requirements being considered exceptional. Boston has one bed for each i io inhabitants and Massachusetts one for each 165, and these never seem too many - indeed, scarcely enough. But the Boston hospitals admittedly draw some patients from other states.

Students of public health and welfare have agreed that any city must have at least one active bed for each 200 of population to meet its obvious obligations and that any state should have one bed for from 200 to 300 depending on the density of the rural population and its proportion to the urban population.

Table II. on the previous page shows conditions in 1921, convalescent and allied institutions and all hospitals for the nervous or insane being excluded.

Classification

Two-thirds of the hospitals in the United States in 1921 were classified as general, one-third as special, i.e. confining their work to tuberculosis, general contagious, mental and nervous diseases, maternity, etc. Nearly all limited their admissions to acute cases, with the result that the lack of provision for chronic cases was the prominent defect.

Finances

The rapid increase in operating costs following the outbreak of the World War was a serious problem to American hospitals. Nearly all hospitals in 1921 admitted three classes of patients: (a) those paying full cost of their care; (b) those paying part of the cost in definite charges; (c) those paying nothing. " Pay " hospitals adjusted themselves to the new conditions by increasing their charges; " part pay " hospitals were generally able to obtain larger rates from patients during the war. Until deflation began there were fewer free patients than before the World War. This circumstance, the increase of (and the payment received from the Federal Government for) soldier patients, enabled the hospitals to meet their increased costs.

Answers to a general questionnaire in 1921 showed the actual investment in buildings and original equipment to average $4,714 per bed, no allowance being made for subsequent increases in values of land or buildings. On this basis the first cost of building and equipping the American hospitals had been $3,279,520,372. Annual maintenance cost for 1920 was $791 per bed. This figure, applied to the entire field, shows a total annual operating cost of $550,287,118. The above figures were compiled by the Modern Hospital with the aid of various agencies and organizations.

Equipment

During 1910-20 there was a marked change in the equipment of the average hospital. The previous development in clinical and pathological laboratory facilities and work continued and expanded. An institution in 1921 had little claim to rating as a hospital unless it had a working X-ray equipment and was prepared to carry out any pathological and clinical laboratory work, including serological examinations, at least to the extent of the Wasserman test. To do this many institutions were compelled to make working arrangements with private firms or with other institutions, but the essential aim - that of making the service available to the patients in the hospitals - was secured. The average mechanical equipment also was much improved.

Medical Education in Hospitals

The Council on Medical Education and Hospitals of the American Medical Association was in 1921 making a real contribution to the professional work of hospitals, as well as developing the fifth or intern year of medical education, by establishing a routine inspection of the hospitals' facilities and personnel for the instruction of the interns. Lists of approved hospitals were published and were of great service, as there were more positions for interns than new graduates in medicine, and a hospital was forced to comply with the requirements for admission to the approved list in order to obtain interns.

New Hospitals

There was a distinct movement in the decade 1910-20 to make hospital service available to ever y one. State legislation enabling rural counties with small populations to combine for the support of one hospital, and encouraging average counties without hospitals to erect and support one, was responsible for the larger part of the increase. Such county hospitals have their work supplemented through private endowment or gift and admit the private patients of the physicians in the county. The need for free service in some counties is very small. The hospital is often in type a community institution quite different from the county hospital in a large county having many private hospitals. In these large counties the county hospital provides largely for free or chronic patients and often acts as a department of public service for the poor.

Organization

The American Hospital Association has both institutional members (hospitals) and personnel members, such as hospital trustees, persons on the medical staff, superintendents and department heads. State associations similarly organized were being formed rapidly in 1921 as state sections of the American Hos pital Association. There was also a Catholic Hospital Association. There were many National associations of the nurses, social workers and dietitians. These were all united in the American Conference on Hospital Service, formed to deal with questions larger than those of any one of the associations. (A. R. W.)

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