H.—3la.

6. CONCLUSIONS AND RECOMMENDATIONS REGARDING FUTURE HOSPITAL POLICY. The Committee finds that there is an overwhelming preference for the treatment of maternity cases in hospitals and is satisfied that, as far as New Zealand conditions are concerned, that preference is justified and to be encouraged. After a full survey of existing hospital facilities the Committee is satisfied that, in general, there has been a very real and progressive improvement, in the maternity hospital services of all types both in respect of the accommodation provided and of their efficiency and safety. The investigation, however, revealed a certain lack of uniformity in this development, especially in respect of the public provision made by different Hospital Boards. It is therefore recommended that a definite and uniform hospital policy be adopted for the whole Dominion incorporating the best features of the present system as follows :— (1) In all country districts it should be the general policy to provide maternity hospital facilities as close to the homes of the mothers as is reasonably possible. Such provision makes it possible for the mother to be attended by her own doctor both in the ante-natal period and for confinement, relieves her of the physical and financial burdens associated with frequent visits to clinics and hospital in a distant centre, and keeps her in closer touch with her family. Admittedly these smaller units cannot be of the ideal maternity hospital standard, but they can give the essentials of safe maternity care. It is considered that the advantages of nearness to the homes of the patients outweigh the benefits to be gained by centralization in bigger units at long distances from the homes. It should be recognized as the responsibility of the Hospital Boards to make this provision for those unable to make private arrangements, and, since in most of these districts it is not possible to develop satisfactorily both a public maternity hospital and a private maternity hospital, it will, as a rule, be better to concentrate on one institution— (a) Where no satisfactory private hospital is available which would be capable of development to meet the full needs of the district it is recommended that a public maternity hospital be established and controlled by the Board and that, in addition to making provision for the nursing treatment of all indigent cases, the Board should accept responsibility for the medical attention of such cases both ante-natally or at confinement when necessary. It is also recommended that such hospitals be made available to the local doctors for the treatment of their private patients. The Committee believes that by satisfactory health-insurance provisions it would be possible to attain the ideal of doctor-attendance for all cases in these hospitals. (b) Where an efficient private maternity hospital is already functioning in the district it is considered that the most advantageous and economical course is to make use of this hospital to serve the public needs by some method of financial assistance which is satisfactory to all those interested. The Committee believes that the most satisfactory method would be by hospital benefit under a health-insurance system. The alternative in the meantime is to arrange for a uniform and acceptable system of subsidy by Hospital Boards. Although some very well managed " mixed " hospitals taking both maternity and medical and surgical cases were inspected and strong arguments were brought forward in some country districts in support of such combined hospitals when strictly controlled, the Committee is convinced that as far as possible the principle of the purely maternity hospital should be developed. (2) In all the larger towns and small cities the policy should be to develop maternity hospitals of a larger and more modern type. It is recognized that the converted private house rarely fulfils all the requirements, and, as far as possible, all new maternity hospitals should be specially constructed for the purpose. The ideal moderate-sized hospital should be large enough to allow of the maintenance of a night nurse and a staff sufficiently large to make possible reasonable hours of duty ; proper staff quarters should be provided; it should have labour-ward block and nursery so placed as to be well removed from the lying-in wards ; and it should have sanitary arrangements and equipment which conform to accepted standards. These provisions are hardly possible if the hospital has less than ten beds. In such communities the number of people requiring some public assistance is so large that the only really satisfactory way to serve their needs is by the establishment of a maternity annexe or hospital in association with the general hospital. This should be regarded as a definite duty of all Hospital Boards, and due publicity should be given to the facilities available. In addition to making this hospital provision the Boards should also be responsible for the medical attention of indigent maternity cases. Having seen how very well the " open " maternity annexe meets the needs of those who desire modern maternity hospital facilities at moderate cost and who wish at the same time to be attended by their own doctors, the Committee is definitely of the opinion that this community-hospital principle should be adopted in all maternity hospitals and annexes of this group. It is also recommended that each of these annexes be placed in the charge of a medical practitioner with special experience in

82