War and accidents – a driver for the NHS and the BOA

Gary Robjent

Gary Robjent is Head of Policy and Public Affairs for the BOA

In preparation for war – and in particular the anticipated and realised Blitz –the Chamberlain Government drew up the Emergency Hospital System (EHS). This followed surveys during 1937-38 that revealed that the 1,334 voluntary hospitals and 1,771 municipal hospitals were organisationally and financially disparate and failing. Two-thirds of the hospitals had originally been erected before 1891, one-fifth before 1861. They were in poor physical state and lacked diagnostic facilities, pathology and radiology, and operating theatres. In addition to the voluntary and municipal hospitals were the cottage hospitals; often established and run by GPs, who carried out the majority of surgery.

The prestigious voluntary hospitals included the teaching hospitals (12 in London, such as Guy’s Hospital, and 10 in the provinces), which had been founded in association with a civic university. Some of the voluntary hospitals had existed for hundreds of years – St Bartholomew’s for over five hundred, but many, smaller had been established following the First World War.

Many of the municipal hospitals had grown out of the infirmary wards of the Poor Law workhouses. By the 1920s, particularly in the big cities, the infirmary sections were larger than the rest of the institution, with resident medical staff and some facilities for laboratory tests, X-rays and surgery. In 1929, when local authorities assumed responsibility for any municipal hospitals still under the control of ‘boards of guardians’, they provided three times the number of beds of the voluntary hospitals. However, most remained largely a ‘dumping ground’ for the elderly and chronic sick – many of whom had previously been under the care of the voluntary hospitals – and would remain there until death. By 1938, councils in England and Wales provided 75,000 general beds (excluding mental health and ‘fever’ beds for which they were also responsible).

In 1935, British Medical Association’s Committee on Fractures and a subsequent cross government study (1939) highlighted the poor outcomes for people injured (mostly in road traffic accidents despite a reduction following the introduction of the Highway Code in 1931). Pre-Second World War, only a few of the larger hospitals had separate orthopaedic wards. However, by 1939, the new specialties such as orthopaedics, were developing in general hospitals; anaesthetics was not yet a fully distinct specialty and a basic knowledge of its techniques was a useful skill for any doctor.

In addition to the prospect of the Blitz, there were other unforeseen consequences of war that prompted the development of trauma care. Industrial accidents in Birmingham had risen by 40% as inexperienced workers entered wartime factories. Widely regarded at the time as a radical plan to treat injured patients in a specialised setting, the Birmingham Accident Hospital was established in 1941 and staffed by specially trained trauma staff – concentrating not just on immediate care, but also on the rehabilitation of these patients. The Birmingham Accident Hospital and Rehabilitation Centre was the last voluntary hospital in the country, and its specified objectives included prevention of industrial accidents.

Similarly, following a review of the attendance at the ‘casualty’ department of the Radcliffe Infirmary, Oxford, the Oxford Accident Service was established in 1941 to provide a unified service for treatment of fractures and all other injuries. Planned in 1940, the aim was to ensure direction and supervision for the ‘casualty department’, to ensure a uniformly high standard of treatment with all injuries admitted to the Accident Service and treatment provided by the specialist departments of the hospital. The majority of the injuries were known to be fractures and soft-tissue injuries; burns and hand infections were also included as ‘accidents’, and managed in collaboration with the department of plastic surgery.

Orthopaedics and trauma care, and the NHS, were inspired and necessitated by the physical and social consequences of two world wars, and the social conscience that arose in response to the impact of the Industrial Revolution.

Unsurprisingly, these factors are also responsible for the creation of the British Orthopaedic Association. Robert Jones, one of the founders of the British Orthopaedic Association, was a surgeon to the Manchester Ship Canal. He witnessed a high accident rate to its 20,000 workers and so organised first-aid services, each backed up by a hospital, staffed with a resident doctor and nurses. Later, in 1916 he persuaded the War Office to reserve 400 military beds in Alder Hey Hospital. Subsequently, Hammersmith Infirmary became a military orthopaedic hospital and by 1918, the army orthopaedic service had 30,000 beds.

In 2023, the BOA continues to support the principles and ethos that underpin the NHS 75 years on. Sadly, it also finds it has a role in supporting colleagues working in conflict zones and disaster areas with its acclaimed battlefield trauma resources.