Medical Services in New Zealand and The Pacific
VII: Organisation for the Control of Sick
VII: Organisation for the Control of Sick
The Government decided on 7 February 1938 that the existing local hospital facilities in New Zealand should be utilised and adapted, if necessary, for the sick and wounded of the fighting forces in war. All treatment was to be arranged by the Health Department.
On this basis the Army Medical Service arranged after the start of the war for only minimum and simple camp hospital accommodation for patients likely to be retained less than forty-eight hours. Other patients were conveyed to the door of the nearest public hospital, where they became the responsibility of the Health Department until fit for discharge. In actual fact it became usual to retain some classes of patients in camp hospitals for longer than forty-eight hours, this by an arrangement with the National Medical Committee and the Department of Health to help in relieving congestion in the civilian hospitals. Medical boarding and treatment of sick and wounded were controlled by the Health Department and administrators, transport and minor treatment were army responsibilities.
Convalescent and medical board depots were to be a responsibility of the Health Department, but this decision was modified in 1940 when War Cabinet ruled that convalescent depots for short-term convalescent soldiers should be an army responsibility. Delay in the page 268 construction of convalescent depots was one of the reasons for the limited use that was made of them.
Had convalescent depots been available, the administration and control of sick and wounded servicemen might have been improved. This was the point at which all patients could have been brought under the control of the Army Medical Service again after their discharge from hospital. As it was, from the time they were admitted to hospitals to their ultimate return to their units, it was not usual for sick from New Zealand camps to come under the Army Medical Service. From the medical point of view the ideal disposal of all army personnel sent to hospitals, if not fit at their discharge to return to their units, would have been to an army convalescent depot. This would have enabled the CO of the convalescent depot to have had all these personnel classified and dealt with accordingly.
Some of these men could then have been sent on leave to their homes and an adequate check kept on them, through ADMS District, and gross and unnecessary extension of sick leave could have been prevented. Some of the men sent on leave could have been required to continue treatment as out-patients at some hospital department. Arrangements regarding this, if not already made by the medical superintendent of the civil hospital, could have been made by the CO Convalescent Depot, who would in any case have kept in touch with such departments to ensure the rapid return to units of all men as they recovered. The movements of all men on sick leave could then have been under complete control.
A great many of the patients transferred to a convalescent depot would normally receive further treatment there. Many would be posted directly back to their units. Others would be given leave by the CO Convalescent Depot according to his discretion before returning to their units, and unit commanders would, of course, be duly notified.
When convalescent depots were in use individual soldiers were quick to see that there would be restrictions on the over-liberal leave conditions hitherto obtaining, and some spoke unjustifiably of unsatisfactory treatment in the depots in order that these units might be short-circuited and the individuals gain more leave through doctors at the civil hospitals. The existing system had operated for so long that the convalescent depots, expensive units to establish, were never used to the full.
Some indication of the extent of sick leave and the possibility of reducing it if a convalescent depot were available was given by the ADMS 4 Division, Lieutenant-Colonel Shirer, in a report to the DGMS on 4 August 1942, when he stated: ‘Co-operation with hospitals and Areas remains good; but sick leave has become a page 269 primary factor associated closely with morale of troops …. A Convalescent Depot is one of the urgent needs, as is some hospital and hut accommodation. The Division has steadily over 600 on sick leave; probably 50 per cent or more of these would be much better in a Depot…. With a few camp hospitals and a convalescent depot much could be done to maintain efficiency and morale, and end the present “sick leave” racket.’
Other ADsMS also spoke of the abuse of sick leave.
Apart from the belated provision of convalescent depots in New Zealand, which could have hastened the return of many men to their units, the Army Medical Service found itself divorced from any control of sick soldiers once they went to public hospital. The DGMS made repeated attempts to get the system changed, but it was not until 1943 that he was partially successful in doing this. In the meantime, and even afterwards, many thousands of pounds were paid out to men who stayed at home on unnecessarily extended sick leave, or waited for some minor operation that would not have improved their medical grading, when they might well have been returned to civilian occupations and served their country in that capacity. The fault was not that of the medical services, but of those who failed to see the importance of professional medical opinion and the need for central medical co-ordination.
Administration of matters connected with army sick was handled by the existing staffs of district and area offices for the first year of the war. The DGMS made representations about securing a central control enabling medical officers at Army Headquarters to fulfil their function and duty in these matters. The decision was made to seek authority for special staff to deal with sick and wounded returning from overseas, as well as sick from New Zealand camps. On 14 August 1940 War Cabinet approved the appointment of special staff ‘to deal with matters relating to sick and wounded personnel from mobilisation camps, mobilised units and territorial units undergoing intensive training’. An officer was appointed to the staff of the Adjutant-General and an officer and NCO at each district headquarters, and an NCO at each of the remaining three areas in each district. From this modest beginning the staff of Sick and Wounded Branch (as it came to be known) grew to a total of 22 officers and 263 other ranks in 1944. When the officer-in-charge of the Sick and Wounded Branch was appointed on 9 September 1940 the DGMS understood that the branch would be under his general direction, and the officer was for a time accommodated in the office of Medical Headquarters. In 1941 the officer and his staff moved within the office of the Adjutant-General, and the DGMS reported that from that time there was a progressive falling-off page 270 in the co-operation between the Sick and Wounded Branch and the Army Medical Service, and that the former took over more and more of the duties which were the real prerogative of the Army Medical Service.
The title of ‘sick and wounded branch’ became a misnomer, from the medical viewpoint anyway, as the branch concentrated on record, or 2 Echelon work, and then to it was added transport arrangements, which were rather Q duties than A duties. Then was added the details of administration of all soldiers due for release from the service, those from furlough drafts as well as those medically boarded. As the system developed the onus was placed on nonmedical officers and NCOs, or laymen, to make medical decisions or interpret medical recommendations to the best of their ability. Action on the findings of medical boards was taken by the Sick and Wounded Branch, which had no medical officer. The branch itself recognised its limitations, but the Adjutant-General did not see fit to improve the system. The peculiar position arose whereby the officer-in-charge got help from a doctor of the Health Department (a Regional Deputy) for hours in the evenings at Army Headquarters to advise him on army medical files. Only a proportion of the files could be thus dealt with, and from 1942 the Health Department officer was not able to give this evening assistance. Yet there was a medical staff at Army Headquaters and there could easily have been a DADMS, Sick and Wounded.
In November 1941 the DGMS recommended the appointment of a medical officer to be in charge of Sick and Wounded Branch to improve the general medical organisation and resolve difficulties in the complex problem of the administration of sick and wounded soldiers, whose care fell to the Health Department as well as to the Army. He was to co-ordinate the control of all sick and wounded soldiers, whether in-patients or out-patients of public hospitals, and provide the needed liaison between the Army, the Health Department, the public hospitals and the Sick and Wounded Branch. But no such appointment was agreed to.
The position continued unchanged and the DGMS again took up the matter with the Adjutant-General on 28 May 1943, recommending that the Sick and Wounded Branch should come under the DGMS, and that a senior and experienced medical officer be appointed to direct and advise the Sick and Wounded Branch on all technical matters. These renewed representations were backed by examples of cases where important medical functions had been usurped, with a liability of dangerous consequences, and by the opinions of the DADMS, Remedial Treatment (Surgical), and Officer in Charge of Treatment, War Pensions Department.page 271
Eventually, on 3 September 1943, it was agreed that the DGMS should appoint a senior medical officer for duty with Sick and Wounded Branch, Army Headquarters. An appointment was made forthwith. This officer had the powers of a Regional Deputy and was to review proceedings of all medical boards. He was also to decide all medical questions arising in connection with the administration of the Sick and Wounded Branch, but it took some time for the branch to develop the habit of referring such questions to him.
Medical boards composed of civilian practitioners of varying degrees of experience could recommend surgical or other treatment and the local Area Sick and Wounded officer take action. The part-time regional deputies usually co-operated with local Area Officers but could not exercise complete oversight. Thus personnel could be referred to hospital for operations obviously not of any benefit to the Army in men who would in any case be discharged Grade III. Men taken in Grade III with disabilities were operated upon for them and discharged on pension for ‘aggravation’. Others were kept on army pay for months waiting admission to hospital for minor operations when they could have been rehabilitated back to civilian life or, if otherwise Grade I, possibly returned to duty and told to forget about the operation. Again urgent action recommended by a camp senior medical officer was sometimes not taken, or the wrong course taken, because of lack of understanding by local officers of the Sick and Wounded organisation.
As long as the control of the Sick and Wounded Branch was vested in non-medical officers under the control of the Adjutant-General, medical matters tended to be inefficiently handled. Patients referred to civilian hospitals were treated too much from the civilian viewpoint without sufficient regard for the army aspect.
Following the appointment of an SMO Sick and Wounded, many weaknesses were discovered. For instance, it was found that soldiers due for discharge, but with very minor disabilities, were retained on full pay, although in most instances the men had resumed civilian employment. They occasionally reported to the out-patients' department of the local hospital and a progress report was filled in indicating that they were still under treatment. On this evidence their pay was still continued. In this category came such common conditions as minor skin ailments, e.g., tinea of the feet; old chronic cases of otitis media with occasional suppuration; and soldiers awaiting admission to hospital for months for non-urgent operations such as tonsillectomy, sub-mucous resection and herniotomy.
When the SMO Sick and Wounded pointed out the long-standing anomalies in relation to the retention of a soldier on army pay to the Officer-in-charge Sick and Wounded, the latter became very page 272 co-operative in amending the situation, although there were difficulties because the Act laid down that soldiers receiving treatment should receive full pay until their treatment was completed or until they became a Pensions Department responsibility.
As SMO Sick and Wounded, Colonel Tennent made several trips around New Zealand in order to meet the Regional Deputies and medical boards and acquaint them with the Army's requirements in the disposal of soldiers who came in the category of ‘sick and wounded’. When the difficulties of the soldier's disposal due to faulty or incomplete medical boards were explained to them they co-operated well, and little difficulty subsequently arose in this connection. Thus the solution was simple enough and vindicated the DGMS's long struggle to get some medical control of important medical matters.
It should have been possible for medical papers to have been referred directly to the Medical Branch, where they could have been examined and appropriate decisions made, and then for A Branch, or Q Branch, to have made the necessary record and transport arrangements. Adequate liaison and integration could surely have been established at Army Headquarters and also at District and Area offices. The medical supervision of troops should never be divorced from medical officers, and administrative organisation should be adapted to conform to this. A Branch, through Sick and Wounded, usurped control in medical matters to itself and rejected medical assistance as long as possible. Had there even been a senior medical officer with authority in the Sick and Wounded Branch all the time, many difficulties would have been avoided, and similar medical representation at Area offices would probably have been of added benefit to efficient administration. If the DGMS could have instructed whole-time medical officers in Area offices regarding army policy as to surgery in Grade II and III personnel, it is likely that the pressure on hospitals could have been reduced, and men otherwise fit could have performed military duties while waiting some minor remedial surgery and while on army pay.
The whole of the medical content of the work of Sick and Wounded Branch should have been under the control of the DGMS, who could have delegated responsibility to a DADMS, Sick and Wounded. After medical decision all routine army action could have been undertaken by the appropriate army branch. As the Deputy Adjutant-General said before the appointment of an SMO Sick and Wounded: ‘In general all administrative action required to be taken by Sick and Wounded Branch depends on a medical decision and it should be possible to state clearly in a set of instructions precisely what action is to be taken when a medical decision has been given’. If the medical decision was given by a civilian page 273 doctor then it should have been subject to check and follow up by the Army Medical Service. In general, however, the work of the Sick and Wounded Branch was very efficiently carried out – it fulfilled an essential function in the administration. It was only in the medical aspect that criticism is warranted.