Medical Services in New Zealand and The Pacific
VII: Hospital Administration and Treatment
VII: Hospital Administration and Treatment
Military Hospitals in New Zealand, 1914–18
At the beginning of the 1914–18 War the repatriated sick and wounded came under the control of the Health Department. Military wards or annexes were provided at the larger hospitals to meet the need of the large numbers of military patients. Difficulties were met, especially with regard to discipline in the hospitals, and in March 1918 Cabinet decided that the Defence Department should page 374 have the sole responsibility for the after-care and treatment of both discharged and undischarged disabled soldiers. The special military orthopaedic teams trained in England became available and special military hospitals and annexes were set up in all the main centres and at Rotorua, Hanmer and Timaru. These provided efficient service and continued in action till the greater part of the work was over, and then were largely absorbed into the civil hospitals.
During the 1914–18 War orthopaedic treatment, due to the dominating personality and energy of Sir Robert Jones, was developed to a high pitch of efficiency. This influence extended to the New Zealand Medical Corps and there was established in our hospitals, especially at Brockenhurst, very complete physiotherapy and plaster departments, splint shops and curative workshops. Medical officers were also sent for instructional courses to Alder Hay and Shepherd's Bush orthopaedic hospitals. These officers on their return to New Zealand were utilised to staff special military hospitals and military branches of the civil hospitals, and eventually became the nuclei of orthopaedic departments in the civil hospitals which inherited the knowledge, the staffs and the equipment provided by the Medical Corps.
(It is interesting to note that vocational training was developed in our hospitals in England in 1917 and that splint shops and curative workshops were in full swing at the same period. Nevertheless, in spite of very strong efforts, these were not provided during the Second World War for a considerable period after the hospitals were established overseas.)
Hospital Administration and Treatment, 1939–45
In accordance with its terms of reference the Medical Committee applied itself to planning the organisation of hospitals in New Zealand in the event of emergency. A very comprehensive scheme was drawn up based on Cabinet's decision of 7 February 1938 that all treatment would be arranged by the Health Department, which was most favourably situated to review the facilities for medical treatment generally, and that where possible men would be treated in institutions nearest their homes.
A medical appreciation of the requirements of the Army on home defence was worked out by Colonel Bowerbank in March 1939. Calculations allowed for a daily sick rate of 0.3 per cent and an average stay in hospital of seven days for 40 per cent, 21 days for 50 per cent, and an indefinite period in hospital for the remaining 10 per cent. After twenty-one days the admissions would balance the discharges. On this basis it was estimated that a total of 1175 beds would be required for sick in New Zealand from the page 375 force expected to be mobilised, and this would entail the provision of extra accommodation by hospital boards at Auckland, Wellington, Christchurch and Dunedin, and possibly at Napier and New Plymouth. Battle casualties in New Zealand at an estimated 6 per cent of troops would require 1594 extra beds.
The plan for emergency hospital organisation was worked out from this basis on the assumption that a home defence force would be actively engaged, and fell into three parts:
Organisation of additional emergency hospitals in certain cities and towns.
The possible transfer of patients from vulnerable areas.
The arrangements for their reception in areas to which they were transferred.
Any of these courses entailed additional emergency hospital accommodation and plans for the evacuation of patients by the hospital boards; and also the staff to look after the patients, as well as equipment. The hospitals were to be classified according to their facilities and staff and were to be grouped into areas with coordinated action under a group officer. The formation of mobile teams within the groups was envisaged. Case history sheets in special envelopes, marked as to the type of case, were to accompany each patient. Transport by train or ambulance car was to be handled by the transport section of the ONS. The Government was to buy and store additional equipment and supplies in suitable localities. A register of medical practitioners was to be drawn up by the BMA and of nurses by the Department of Health. Emergency helpers were to be recruited, including members of the Red Cross Society and Order of St. John. Three convalescent depots of 400 beds each under civilian control were suggested. The operation of the scheme was to be under the Department of Health. The scheme as outlined was purely general in form and the implementation was left largely to the hospital boards.
The plan had naturally to be adapted to suit the situation when a home defence force was not mobilised on the scale originally catered for, and, instead, men were called up primarily for overseas service after training in mobilisation camps, and the home defence force was gradually built up but never actively engaged in New Zealand. Further adaptations had to be made to provide hospital treatment for the sick and wounded invalided back to New Zealand from the overseas forces.1
Instructions were issued to the hospital boards on the care and treatment of army sick and wounded. (See Appendix A.)
The decision made by Cabinet, on the recommendation of the National Medical Committee, that the Health Department should have the full responsibility of hospital treatment in New Zealand of the armed forces for all cases hospitalised for more than forty-eight hours was a very important one. As stated by the DGMS in November 1939: ‘The Medical Committee of the ONS advised, the Committee of the ONS recommended, and Cabinet confirmed the principle that the Army will retain in Camp Hospitals soldier patients only for a period of 24 to 48 hours and that all cases of serious illness or injury, or cases requiring treatment for a longer period, shall be evacuated to the base civilian hospital. That from the time of evacuation until the soldier returns as grade I he will be the sole responsibility on the one hand of the Health Department which will make the arrangements, and on the other hand of the Hospital Boards which will arrange for the necessary accommodation. That the Health Department shall be wholly responsible for the organisation and control of Convalescent Hospitals.’
This decision had far-reaching effects. It determined, firstly, that very little provision needed to be made at the military camps for the accommodation and nursing of patients. It also, naturally, led to congestion at the main hospital near which the military camps were sited. This congestion was accentuated by cases being referred by the Army for remedial treatment and also by the introduction of hospital benefits under the social security legislation.
A hospital staffing problem also arose due to many of the medical men and other personnel attached to the hospitals proceeding overseas. The policy seems to have been determined for several reasons. First, there was the saving of medical and nursing personnel by concentrating the work in the established civil hospitals. Then there was the economy of building, both of existing buildings and especially with regard to any erection of new buildings which, if page 377 attached to existing hospitals, would after the war be of immediate use for the civil population. Finally, there was political antagonism to military control.
The epidemic of influenza in November 1939 found the civil hospitals not fully prepared, and the point was raised that the Army had been criticised for not having made provision in military camps for influenza patients, though this was not an army responsibility. It was conceded, however, that the extent of outbreaks of such a nature was absolutely unpredictable and that generally speaking hospital boards, with the assistance of the Army Medical Service, had met the position expeditiously. With the experience gained it was held that the measures to be taken in the future would probably be adequate. A hospital, at first staffed by the Army and later by the Wellington Hospital, was opened in the racecourse grandstand at Trentham in November 1939, and officers of the Health Department had visited different parts of New Zealand to consider buildings, such as racecourse grandstands, halls, etc., which could be utilised as emergency hospitals to cope with any epidemic. (Note: A number of such buildings, notably Trentham and Ellerslie grandstands, were used by the hospital boards for subsequent epidemics.)
Arrangements were made for the hospitals to furnish regular returns to the Army Department so that next-of-kin could be informed. It was agreed that the local Area Officer or a military medical officer should be in touch with hospitals daily, and that there should be close co-operation between the local army authorities and the hospital superintendent to avoid any unnecessary stay in hospitals by soldier patients. (Note: An army organisation known as the Sick and Wounded Branch was later developed. See earlier chapter.)
To ensure that Army obtained the necessary information, written and verbal, concerning army patients, it established in the main centres a Hospital Officer for sick and wounded with a clerical staff. The officer's duties were to get information at once concerning any patient admitted in order to notify the next-of-kin, to collect hospital notes of treatment for the patient's file, and to arrange through his Sick and Wounded area officer for medical boarding by application to the Regional Deputy. He also arranged all transport, leave, or transfer to another hospital. He saw that medical documents and file and an escort attendant went forward with the patient to the next hospital. This was found necessary owing to delay in some page 378 hospitals in providing the information required. Applications for admission to hospital went from Army to this officer and he arranged on the spot with the hospital. At the main hospitals accommodation was provided by Army for this sub-branch of the Sick and Wounded Branch, whose administration was at first centralised in the office of the Adjutant-General, but which later was decentralised to army areas.
The disposal and treatment of convalescent patients from camp and civil hospitals was a matter which had not been properly provided for and which was further discussed at an important conference held on 17 July between representatives of the Health Department, the Army and the hospital boards.
The Director-General of Health stated that the disposal of convalescents presented a most difficult problem both to hospital boards and to the Army, particularly in regard to men recovering from diseases such as influenza. While reasonable provision was made for the long-term type of convalescent recovering from operations or from chronic protracted illnesses, hospital boards did not customarily provide for those recovering from complaints such as influenza, who require little more than rest and whose convalescence might normally be expected to be rapid. In the case of civilian patients it was the practice to discharge them as soon as the need for active medical and nursing attention ceased, leaving patients to make their own arrangements in regard to the recuperative period between hospital treatment and the point at which they could resume their ordinary occupations. Military patients recovering from influenza, who had to be kept in hospital until they were fit to return to camp and take up duty within forty-eight hours, therefore presented a new problem to hospital boards.
Colonel Mead, the Adjutant-General, stated that the same difficulties arose in regard to men treated in camp hospitals. It was not in the interests of discipline to have these men on excused duties in the camp except for very short periods, and it was not practicable in most cases to grant leave and send them home for a few days' convalescence. Some special provision such as the establishment of convalescent depots should be made, but in view of the Government's policy that the hospitalisation and treatment of soldiers was to be the responsibility of the hospital boards and the Health Department, the Army Department was powerless in the matter.
Considerable doubt was expressed by some of the hospital board representatives as to whether provision for convalescents could be page 379 regarded as coming within the definition of ‘treatment’ and whether, therefore, this was a hospital board function.
In the general discussion it was found necessary to distinguish clearly between the two types of convalescents:
The long-term convalescent who still required a measure of specialised medical attention and graduated exercise, etc., under expert supervision. (These would be dealt with principally at special convalescent hospitals provided by the Government at Hanmer and Rotorua.)
The short-term convalescent who required no further active hospital treatment, but who merely required hardening off and some form of exercise until such time as he was fit to resume normal military duties.
The army representatives agreed that provision for the latter class was not a function of the hospital boards and, moreover, that they were not suitable cases for special convalescent hospitals such as Hanmer and Rotorua.
The conclusion reached by the meeting was that two separate types of institution would be required:
Convalescent Hospitals, such as Hanmer and Rotorua, where active treatment such as physiotherapy, etc., would be provided.
Convalescent Depots established in the proximity of military camps for the reception of convalescents who merely required hardening off, and where physical training could be provided until such time as they were fit to return to duty.
The consensus of opinion in regard to the responsibility for military patients was that the actual hospital treatment of the patient should be the function of hospital boards (the term treatment to be interpreted liberally and patients to be kept, if necessary, for a slightly longer period than was the practice with civilian cases), and that at the conclusion of such hospital treatment the patient should become either: (a) a long-term convalescent whose further treatment at a convalescent hospital such as Hanmer or Rotorua would be the responsibility of the Health Department, or (b) a short-term convalescent requiring admission to a convalescent depot for physical training and hardening off, the provision of which should be the responsibility of the Army.
It was formally resolved that a recommendation be made to the Government to this effect.
It was also decided that in the event of convalescent depots being established by the army authorities the Health Department and page 380 hospital boards would be consulted as to the location of the buildings in order that, on the cessation of hostilities, such buildings might serve a useful purpose. In a measure the recommendation made to the Government by the conference as regards the institution of army convalescent depots was contrary to the original Government policy of using only civil institutions, on which the Army was to be entirely dependent.
However, a year later, on 18 July 1941, War Cabinet approved an expenditure of £325,835 to build three convalescent depots under army control. Construction on the depots at Raventhorpe (ten miles south of Papakura), Silverstream and Burnham began in 1941 and was completed towards the end of that year. Each depot had a capacity of 300 and the staffs consisted of army medical personnel and special army instructors, some of whom were obtained from the Physical Welfare Branch of the Education Department. Provision was made for an administration block, physiotherapy and massage departments, a gymnasium, a lecture hall, a picture theatre and sports grounds.
Silverstream, however, was not used as a convalescent depot for Central Military District as, upon its completion, it was made available to the United States medical services then in New Zealand, and after it was vacated by the United States Forces it was taken over by the Wellington Hospital Board. Alternative sites for a convalescent depot in Wellington were considered, but nothing was finalised. In Trentham Camp unfit men were temporarily attached to the NZMC Training Depot until fit for duty. As far as convalescent patients from civil hospitals in the Wellington area were concerned, they mostly went direct to their homes – as indeed they seemed to do from most civil hospitals, for the other two convalescent depots never functioned to capacity. Liaison between the military and civil authorities as regards hospital patients was not fully established, and as long as there existed the loophole of allowing patients to proceed to their own homes on discharge, advantage was bound to be taken of it. There was something to be said for this course, especially psychologically, but it certainly entailed a considerable wastage of manpower.
For instance, in the eighteen months just prior to April 1942, over 2500 cases from the Racecourse Hospital (Trentham) alone were granted sick leave for periods from three days to three weeks. When men went home on sick leave, not a few of them sent certificates from local practitioners recommending extensions of their leave, and there was no option but to grant the extensions.
In addition, a time lag in Sick and Wounded Branch getting the men back into camps was unavoidable, and, even then, numbers page 381 required admission to a convalescent depot before they were fit to resume full duty with their units.
Prior to the opening of the Services Convalescent Hospital at Rotorua on 18 March 1942, a few convalescents not requiring any treatment were sent, mainly from the Waikato, to the Bryant House, Raglan. The convalescent hospital at Rotorua had 150 beds, was run by the Health Department, and was used by all three services. It was the convalescent hospital for all orthopaedic cases in the North Island, and usually cases requiring only massage or physiotherapy were sent there. It was primarily for patients returned from overseas, but as these never filled the hospital it was used for New Zealand service patients and an occasional civilian case. The hospital was equipped for physiotherapy, occupational therapy and minor surgery, including facilities for plaster technique, and was handy to recreational facilities and baths. There were nursing sisters with overseas military experience on the staff.
Cases of neurosis were not sent to Rotorua but to Hanmer Convalescent Hospital. Prior to the war, Hanmer was purely a centre for functional neurosis cases, and during the war continued to be the centre for the treatment of such cases, military and civilian. However, as a counterpart to the Services Hospital, Rotorua, the Health Department reopened for orthopaedic cases two old wards built during the First World War. With the extension of the already existing massage and physical training facilities, Hanmer Hospital was able to deal with the same type of case as the Rotorua Hospital. As there were fewer patients from overseas than anticipated, the Hanmer Hospital was able to accommodate other cases and advantage was taken of this by the Christchurch Hospital, which transferred there not only fracture cases in plaster or requiring physiotherapy but any type of case requiring convalescence. (Later in the war a Plastic Surgery Unit was established at Burwood Hospital, Christchurch, first under army control and later under civilian control.)
The original plan of the Medical Committee for treatment of sick did not make adequate provision for army personnel in the convalescent stage after discharge from hospital. Difficulties were encountered soon after troops were first mobilised, and not all of them were successfully solved during the course of the war. The convalescent serviceman illustrated the weakness of the divided control of medical administration. His control came partly under page 382 the Health Department and hospital authorities, partly under the Army Medical Service, and partly under the Sick and Wounded Branch of the Adjutant-General's office. Generally speaking, the convalescent serviceman was able to make the most of the lack of liaison and unity, and most of his convalescence was spent at home, with a consequent wastage of manpower during the administrative delays involved in his ultimate return to his unit. The situation reached its extreme of inefficiency in the cases where servicemen were granted extensions of sick leave on pay by non-commissioned officers of the Sick and Wounded Branch and resumed their civilian occupations temporarily while still members of the forces.
The utilisation of convalescent depots as training centres for convalescents, such as was seen in Britain and also in the British Army overseas, would be a very distinct improvement in our army organisation, and the provision of physical training personnel of the British type would undoubtedly be of enormous advantage to our New Zealand forces.
Treatment of Invalids from Overseas
The Director-General of Health at a conference on 17 July 1940 outlined the procedure laid down for the reception of sick and wounded service personnel returning to New Zealand from overseas.
By arrangement with the Army Department several weeks' notice of returning men would be received and a list with details of the patients, nature of disabilities, etc., would be available to hospitals. These details would be confirmed if possible a day or two before arrival, and any modification necessitated by changes in the condition of patients during the voyage would be notified.
Patients on disembarkation would be sent to the four main centres and would be admitted to the four principal hospitals, which would act as clearing houses for the distribution of patients. The principal base hospitals would retain those cases from their own hospital board areas, together with those requiring specialist treatment from other adjoining board areas. The remaining patients would be transferred to their own district hospitals within forty-eight hours. (Actually hospital ships usually came to Wellington and clearance was effected through the Casualty Clearing Hospital on Aotea Quay to local hospitals.)
Details were given by the Director-General of Health of the extra accommodation being provided at the four main hospitals in order to deal with these patients. Estimates had been made by the Army Department of the numbers likely to be returning each month and the proposed accommodation was based on these figures. The number of beds required in the four main hospitals, both for the page 383 treatment of their own patients and for the temporary reception of those who would be transferred to other districts, was approximately:
Additional buildings were required for this purpose and the Government accepted the responsibility for the provision of these extra blocks.
Arrangements were made for the erection of blocks of 150 beds at Auckland, 100 beds at Wellington and 60 beds at Christchurch. In Dunedin the Hospital Board already had subsidiary institutions which would be available. It was explained that the new blocks being erected would not necessarily be used for soldier patients, but by internal rearrangement wards in the main hospitals would probably be freed for them.
Action had also been taken to bring the orthopaedic departments of the main hospitals up to date and to provide occupational therapy, gymnasiums, etc. Arrangements were made by the Government for the acquisition of the necessary orthopaedic equipment.
The hospitals at Auckland, Wellington, Christchurch and Dunedin were recognised by the Health Department as base hospitals for the treatment of orthopaedic cases, and all such cases were referred to one of these hospitals. Patients were under the care of orthopaedic surgeons, who could arrange for further treatment at the hospital nearest the patient's home. It was decreed that all orthopaedic operations had to be performed at a base hospital, and all patients requiring such operations were transferred from local hospitals where they were under treatment. The facilities for physiotherapeutic treatment at Hanmer and Rotorua hospitals were used and patients were often transferred there.
Clearing Hospital, Aotea Quay, Wellington
In 1941 a Clearing Hospital was erected on Aotea Quay, Wellington, to receive sick and wounded servicemen from overseas. By a decision of the War Cabinet of 20 February 1941, it was staffed and administered by the Health Department. It was considered that before any man was allowed to depart from the Clearing Hospital a thorough clinical examination was essential. This was not only to determine as precisely as possible what further treatment was necessary, but also, in the serviceman's interests, to ensure that a complete and authoritative record of his condition on arrival in New Zealand might be available in connection with any future claim for war pension or other assistance.page 384
Four medical boards were made available immediately upon the arrival of a hospital ship to accelerate the clearance of patients. Serious cot cases were naturally not held for boarding at the Clearing Hospital but were sent direct from the ship's side to Wellington Hospital for attention until they were ready for transfer to their own districts; or else, if seriously ill, patients were held on the hospital ship and taken to Lyttelton on the ship. Except at first, when the Health Department staffed the ambulance trains, the Army was responsible for seeing men to their destinations.
The Clearing Hospital had accommodation for 288 patients. There were six wards, each with its kitchenette, sister's duty room and other necessary services. In addition there was a large lounge and dining room for patients, a staff dining room and large central kitchen. There was also a suite of medical board rooms, X-ray room and dental examination room.1
Arrangements were made to demobilise rapidly all returned men no longer fit for military service. They thereby became civilians and their treatment was the responsibility of the War Pensions Branch of the Social Security Department. There was, however, an inherent weakness in this form of administration. The Health Department as organised had only an advisory authority in hospital matters. It had no executive control and no executive staff. The individual hospital boards had full control of their own administration, which was limited to the treatment of patients in their institutions. The Hospital Boards Association, which forms the link between the hospitals, has again no function except the co-ordination of policy – it has no function in the treatment of patients.
The hospitals themselves had only limited means of co-ordinating hospital treatment for servicemen and no means of providing transport either of the service personnel in New Zealand or of the sick and wounded arriving from overseas. The difficulties were overcome at first by the enlisting of voluntary organisations and workers and the army authorities to help fill the breach. Later the Sick and Wounded Branch took over the responsibility of administration of the transport of patients to and from the hospitals, both from camps and depots and from overseas, and also of cases for remedial treatment. It acted as liaison between the hospitals, the Army and the Health Department, including the Regional Deputies. At first it did everything from a central office, but later decentralisation was carried out with a natural increase in efficiency.
Plastic Surgery Unit – Administrative Problems
Before the outbreak of war a scheme in regard to plastic surgery was submitted to the DGMS by Dr H. P. Pickerill, the only highly specialised plastic surgeon in New Zealand at that time, he having been attached to the special hospital at Sidcup, England, in the First World War. The scheme recommended plastic surgery for New Zealand soldiers in New Zealand.
In November 1939 the question of plastic surgery came in for further consideration. At that time the presumed location of the New Zealand Division was England and the DGMS considered that treatment in England would be preferable. The matter was referred to the National Medical Committee for consideration, but was presumably deferred until more definite information was available on the location of the New Zealand Forces.
Sir Harold Gillies, a New Zealander well known as a plastic surgeon in the First World War and in England between the wars, offered, in a letter to the Director-General of Health in February 1940, to accept one or two suitable medical officers for special training in plastic surgery so that they might carry on the work for New Zealand soldiers. The offer was accepted by the National Medical Committee on 14 June 1940, the DGMS undertaking to select one or two suitable medical officers.
The selection of suitable surgeons was not an easy matter. The chairman of the Royal Australasian College of Surgeons suggested the appointment of a surgeon doing post-graduate work in England. Towards the end of 1940 two such junior New Zealand surgeons were chosen, commissioned in the NZMC, and began special training. As recommended by Sir Harold Gillies, their courses were to be short ones to enable them to undertake primary treatment in 2 NZEF. Sir Harold also recommended that a more senior surgeon be chosen for a course of twelve months, which would enable him to continue necessary treatment in New Zealand. (Dental officers had similarly to be trained.)
This arrangement, involving the ultimate establishment of an army medical unit as part of a civil hospital for the treatment of men invalided from the overseas forces, was not in accordance with the general policy of hospitalisation of sick and wounded servicemen. Probably the DGMS had in mind the special army orthopaedic units which functioned with marked success in the Christchurch Hospital and at Trentham Camp during the First World War. It would seem that at the outset the National Medical Committee should have explored the possibility of sending surgeons and dentists for training in their civilian capacities, in spite of the fact that the original offer of Sir Harold Gillies specified ‘medical officers’, as probably he did not have in mind any strict interpretation of the term. It was a Health Department responsibility under the policy of providing for all hospital treatment in New Zealand in civil institutions.
In their training in England the medical and dental officers were given every facility and help by the leading specialists, both surgical and dental. They then joined the 2 NZEF in the Middle East, where they were attached to different medical units, the main plastic centre being set up at the Helwan Hospital, Captain Manchester1 being the surgeon in charge, and the other two junior surgeons being attached to other medical units as the work required. A special bath unit was set up in Helwan Hospital and proved of great value, not only in cases of burns but in the treatment of ordinary wounds.
Major Brownlee, not being required in New Zealand, spent some time visiting all medical units in 2 NZEF and explaining the latest treatment of facio-maxillary and other cases requiring plastic surgery, and then proceeded to New Zealand to set up the main plastic unit there, taking with him Captain Gilbert,2 the senior dentist, and equipment which had been obtained in England. He arrived back in New Zealand in September 1942. The unit began to function at the end of the year as a department of the Christchurch Hospital and under the control of the North Canterbury Hospital Board.
1 Lt-Col W. M. Manchester; Auckland; born Waimate, 31 Oct 1913; medical practitioner; RMO 22 Bn 1940; seconded for plastic surgical training in UK, Nov 1940; 1 Gen Hosp 1942–43; asst surgeon, Plastic Surgical Unit, Burwood, 1944; OC Plastic Surgical Unit, Burwood, 1944–47.
This arrangement had been agreed to by the DGMS and the DGH and treatment was to be available for members of the armed forces, and also for civilians, but the question as regards army or civilian status was to be reviewed in twelve months' time. The department started functioning under dual control with some army and some civil personnel, and under both army and hospital board administration. In November 1942 difficulties arose as to the continuous treatment of the cases as they left the forces and returned to civilian status, and arrangements were made for the patients to retain the privileges of army personnel. The position was anomalous and it would have required great tact and skill to carry on without friction.
War Cabinet, in January 1943, approved the expenditure of £4500 on alterations and additions to Burwood Hospital to provide a plastic surgery unit. (The ultimate cost was £10,000.) The Army Department was to supply the special plastic surgeon, a dental officer trained in maxillo-facial work, a junior medical officer and three medical orderlies. The Hospital Board was to supply all other staff, including nursing and domestic staff. Certain special equipment was to be provided by the Army Department and the usual hospital services by the Hospital Board. The accommodation at first was thirty-six beds. The unit opened at Burwood on 8 May 1943.
The available beds were soon occupied, and by October 1943 there was a waiting list of about forty military personnel. Expansion as regards accommodation and staff was called for. At the same time it was felt that the civilian nurses should be transferred to the army staff to make for smoother working.
A conference between the Minister of Health and representatives of the Army and Health Departments was held on 5 November 1943. The extension of accommodation was arranged and it was agreed that the Army should provide all the staff. The Director-General of Health, who was not at the conference, subsequently disagreed with the proposal regarding staff, anticipating that considerable dissatisfaction would arise on the part of the nursing staff of the Burwood Hospital on account of the disparity in pay and working conditions between the army nursing staff and the civilian nursing staff, and that difficulties would arise as regards hospital services. The conference arrangements were therefore held in abeyance.
The system of dual responsibility for accommodation and staffing was not working satisfactorily. One solution suggested by the Director-General of Health was to convert the plastic surgery unit from a partial to a complete military unit, independent of civilian page 388 control, and transfer it from Burwood Hospital to a military camp close to one of the main centres. This was investigated but suitable hospital buildings were not available. The other solution was to convert it into a civilian department of a public hospital. The senior plastic surgical specialist, Lieutenant-Colonel Brownlee, indicated that he was not prepared to serve in a civilian capacity.
A conference between representatives of the Army and Health Departments and the North Canterbury Hospital Board on 21 March 1944 agreed to a policy, which was, in substance, a continuance of the original arrangement. Additional accommodation, as well as massage and occupational therapy departments, was to be provided. It was a compromise solution. Some finality had to be reached to overcome a deadlock in which the treatment of patients might be impaired.
Friction, however, still continued to develop and in September 1944 the resignation of Lieutenant-Colonel Brownlee was accepted. Lieutenant-Colonel Manchester, who had done excellent work in plastic surgery at Helwan Hospital and had had by that time long army experience, was appointed in charge of the department.
Smoother running was soon evident and further efforts were made to overcome the accommodation problem and the shortage of staff. The system of dual control was, however, ultimately eliminated when the plastic surgery unit became a wholly civil unit on 1 March 1945. It continued to treat patients from the armed forces as well as civil patients and functioned with great success.
In retrospect it would appear that the establishment of a plastic surgery unit in New Zealand under dual control was doomed to failure. Cabinet had definitely decided that all hospital treatment in New Zealand should be under the control of the Health Department and carried out by the civil hospitals. There was antagonism to the establishment of military hospitals.
In spite of this the senior personnel of the proposed unit were appointed as army officers and came under the control of the DGMS. This was essential as far as the overseas work in 2 NZEF was concerned. It was unnecessary with regard to the personnel of the unit working in New Zealand, who could well have carried on as civilians. If it had been agreed that a services hospital be established under complete control of the DGMS (with the plastic unit attached), then smooth and efficient running could have been expected. Success might even have attended the unit if it had been segregated as a complete military block attached to a civil hospital, in a similar manner to the orthopaedic unit in the Chalmers block of the Christchurch Hospital in the 1914–18 War. It was too much, however, to expect that the department as constituted page 389 would function smoothly in an atmosphere antagonistic to any military control of hospital treatment.
Dual Control of the Service Patient in New Zealand
The Director-General of Mental Services was never satisfied that the plan as approved by the majority of the National Medical Committee avoided the difficulties of dual control by the Health Department and the Army Department which had been found unsatisfactory in the First World War. He contended that the lessons learnt from the experience of the previous war, when certain functions of the Health Department were ultimately taken over by the Defence Department, were not applied. The soldier, he maintained, was primarily the responsibility of the Defence Department and, though it was necessary and indeed advisable to make use of the hospital accommodation provided by the civil hospitals, the soldier, even while an in-patient of the civil hospital, was still the responsibility of the Army.
The Director-General of Health considered that there was no real difficulty as regards dual control. He held that the soldier remained the responsibility of the Army, and that the Hospital Board became a contractor supplying hospital care and treatment.
The opinion originally expressed by a majority of the National Medical Committee (not shared by the DGMS) that ‘discipline and control of the sick soldier could be equally well maintained by civilian superintendents and staff’ was in some measure disproved. The Army was called upon to appoint full-time NCOs (not New Zealand Medical Corps) to assist in control of service patients at hospitals. However, in the four main centres and other hospitals there was generally little trouble as most of the patients were bedridden and under treatment. At Rotorua Convalescent Hospital there was never any trouble.
From Dunedin, where there were fewer patients and where the soldiers were in wards with civilians, there were complaints that sick and wounded returning from overseas had no privileges regarding visitors. In other centres relatives could visit the soldiers' wards daily, but in Dunedin with mixed wards an attempt was made to restrict visitors to civilian hours. This difficulty was overcome. The only places where there was any real trouble was at Hanmer Convalescent Hospital, Pukeora Sanatorium and Burwood Plastic Surgical Unit.
The Director-General of Health pointed out that there were few, if any, complaints from public hospitals. Hanmer and Pukeora page 390 hospitals were stated to be always notorious for disciplinary troubles, even with civilian patients, this being due to the class of patient admitted.
To understand the causes, one must know the history of the policy laid down by Cabinet. Until 1943 the service patient was kept on service pay for only twelve months, and if still an in-patient automatically ceased service pay and went on to a pension if he would not be fit for a higher grade than III. This in fact implied that all overseas sick and wounded still on treatment were downgraded to Grade III.
Thus at Hanmer there were three kinds of patients: the man on home service; the ex-overseas man still on treatment; and the ex-overseas man, not now a soldier but a civilian, and under treatment as a war pensioner.
These three types, many of whom were up-patients merely convalescing, did not mix. There were many complaints from the Medical Superintendent and the Army provided a senior NCO to be on the spot to control discipline. However, he had no control over the ex-soldier now a civilian, and it was not until the soldier was kept on army strength and pay until completion of his treatment that complete disciplinary control was maintained.
At Pukeora Sanatorium conditions were worse as there were the following types of patient: home servicemen, returned soldiers from overseas (some of them civilians again), and civilian patients.
With the change of policy, whereby patients remained in the service on pay, better discipline was maintained.
Modifications of Hospital Policy
The Army Medical Service had arranged for only a minimum of camp hospital accommodation, while the Health Department had arranged with the respective hospital boards for hospital accommodation based on the medical appreciation drawn up by the Director of Medical Services for the defence of New Zealand on 31 March 1939.
Within a few weeks of the onset of war it was necessary to modify this, as the Director of Health was not prepared to accept for in-patient treatment soldiers suffering from venereal disease. In consequence of the ruling of the Minister of Health, small hospitals were erected in the three main camps, Papakura, Trentham and Burnham, to deal with all cases of venereal disease in the Army and Air Force in the three military districts, and this arrangement worked very satisfactorily.page 391
Again as a result of a War Cabinet recommendation in 1940, the Cabinet again modified its original decision and ruled that convalescent depots for short-term convalescent soldiers should be placed fully under the control of the Army.
This decision, in the opinion of the DGMS, was largely due to the realisation that the Health Department, almost entirely an administrative body primarily concerned with the preservation of health and the prevention of disease, did not have the staff available for running a hospital or convalescent depot when the hospital boards were not prepared to accept the responsibility.
Evaluation of Hospital Policy during the War
In accordance with the immediate pre-war decisions of Cabinet, the Army Medical Service erected only minimum camp hospital bed accommodation, which was all that was necessary if patients were to be retained for only forty-eight hours. This forty-eight-hour rule resulted in an unnecessary number of minor disabilities being transferred to the base hospitals. The direct result of this was that base hospitals, especially at Wellington and Auckland, which were chronically congested before the war and with long waiting lists, became still further congested and embarrassed by the daily admission of men with minor disabilities and mild infectious diseases, who in civilian life would have been treated at home. These base hospitals had highly trained staffs, elaborate departments and equipment for dealing with cases of the most serious and difficult diseases, and the overhead cost of a bed in one of these hospitals was very great in comparison with that of smaller hospitals dealing with cases of minor diseases and disabilities.
The Health Department did everything possible to meet the ever increasing demands of the Army, but it could not but be acknowledged that the system, modified though it was after the onset of war, was still clumsy and prevented that close co-operation which was so essential between the military camps on the one hand and the hospitals on the other.
The DGMS did not advocate any revolutionary change in the administration or control of the civilian hospital or its soldier patients, but sought means whereby closer contact could be developed between the Army Medical Service and the Sick and Wounded Branch of the Army on the one hand, and the hospital boards on the other, and measures of dual control eliminated in order to increase efficiency and bring about a better understanding on the part of the general public and the soldier. This was not a criticism of the Department of Health or of the National Medical page 392 Committee, but it was felt that certain of the duties which the Department of Health had been called upon to carry out were more properly those of the Army Medical Service.
There is no doubt that the latter was in a position to look after a large proportion of the minor sickness cases, and in fact did retain many patients in camp hospitals for up to a week. The Army Medical Service also could well have been made responsible for the sick and wounded soldiers immediately upon discharge from hospital. In a measure the Sick and Wounded Branch of the Army assumed control here, but the disregard of the branch for the necessity for professional medical opinion led to a number of shortcomings involving a delay in the return of soldiers to duty.
Generally speaking, the policy of all treatment being arranged by the Health Department did enable requirements to be met adequately during the war, but there were some fundamental weaknesses. The most important was that there was never any single individual, or even department, with absolute control over the army sick and wounded. The Health Department could act only through the local hospital boards, and actually had no real control over any individual hospital. The Director-General of Health could request and bring moral pressure to bear on hospital boards, but he could not dictate to them. Difficulties were multiplied when hospitals which were generally overcrowded prior to the war had to cater for additional patients as a result of the Government's inauguration of social security hospital benefits.
The Director-General of Health expressed the opinion after the war that the decision to put the responsibility on the Health Department was a wise one. The building of special military hospitals would have been costly and difficult with the shortages of staff and materials, whereas the civil hospital service had a Dominion-wide coverage. He considered that these hospitals cared for the army sick and wounded smoothly and efficiently with the maximum economy in medical manpower, supplies and equipment. Permanent benefits accrued to the hospitals from new buildings (some built as convalescent depots for the Army or hospitals for the United States troops) and from expanded and improved special departments.
The actual admission and treatment of New Zealand service personnel in the civil hospitals seems to have functioned satisfactorily apart from the congestion caused in the hospitals. Arrangements were made to alleviate this by providing more camp hospital accommodation, although officially the forty-eight-hour period was never altered.
New buildings were also erected at the main hospitals and this helped considerably. Strain was thrown on building construction by page 393 the necessity of making provision for the American forces stationed in New Zealand, but the hospital buildings erected were later of great use to the civilian hospitals in these areas.
The rigid curtailment of the treatment of patients in the military camps seems to have created unnecessary difficulties in the civil hospitals. If provision had been made for the treatment of minor illness in camp hospitals there would not only have been a considerable saving in sorely needed and expensive hospital accommodation, but there would also have been more provision for the training of medical military personnel in the camps. The camp hospitals would not have required expensive buildings or equipment and could have been run by the camp medical and nursing personnel.
The larger question of the establishment of military hospitals or military annexes of civil hospitals as already mentioned has several angles. From the military point of view there would be many advantages in the establishment of military hospitals in New Zealand. There would be the natural ease in administration and control, the return of service personnel to convalescent depot or duty, the boarding for discharge or for grading, the retention of discipline and morale. A training school for service overseas would be available for officers, sisters and other army personnel. Exchange of personnel would be possible between overseas and home forces. Most important of all would be the treatment of returned servicemen by medical personnel with experience of their special problems. The establishment possibly of one central hospital and service wings in the other main hospitals would be sufficient, the special departments of the civil hospitals being naturally utilised to prevent duplication.
There seems to have been some antagonism to the segregation of military personnel in the civil hospitals, and, even when segregated, ex-service officers when available were not given control of their treatment, which would have seemed logical and psychologically sound.
The difficulties that arose as regards discipline would have been obviated at least to some extent by the understanding of an ex-service officer. This does not mean that the ex-service patient should be treated differently from the civilian. There is, on the contrary, much to be said against the, to many, quite unnecessary and wasteful dispensations of all sorts of extras, including cigarettes, to ex-servicemen suffering from even ordinary ailments contracted in New Zealand. The money spent could surely be put to better use.
The obliteration of the military identity of the ex-service patients has also made it impossible to obtain satisfactory data concerning their hospitalisation. The arguments against segregation have been already stated as being economy in hospital buildings, accommodation page 394 and staff, and the prevention of any wasteful hospital construction not able to be utilised afterwards for civilian use. It is felt that some agreement could be reached so as to satisfy both points of view and that certainly political viewpoints should not enter into the question. There should be a co-ordinated medical service available for emergencies, administered by the most experienced men available, and if the armed services are functioning they should be called upon to give as much assistance as possible and not unnecessarily overburden the civilian services.