Robert G. Evans

The Transformation of Australian Hospitals between the 1940s and the 1970s

In western countries hospitals have become central components in systems of medical care and institutions of vital interest to their people. Many were established early in the nineteenth century as charitable institutions with mainly welfare roles. Through the twentieth century, their therapeutic activities expanded and they are now large complicated organisations. In Australia similar public hospitals began to emerge in the mid–nineteenth century. Their evolution has, over their long existence, been determined by diverse pressures of a medical, social, economic, and political nature. This article will examine the forces which shaped two Australian public hospitals in the third quarter of the twentieth century, a period of great change in both medicine and society.

History

Hospitals have been the subject of numerous histories. Some of these histories have explored their role in society and in medicine, while others have commemorated the life and work of individual institutions. The latter often have been commissioned narratives dealing with intramural events, the buildings, the clinical services, the administrators, and the staff—usually physicians. Relatively few have attempted to describe how the institutions evolved.¹

There have been a number of general studies on the history of hospital care in Western countries. Those dealing with Britain and the United States are most relevant to Australia. Charles E. Rosenberg had stated that the development of American hospitals can be best understood by studying the medical profession. For the twentieth century that meant studying specialisation as the dominant movement in medicine. He argues that hospital development and specialisation were mutually dependent processes.²

George Weisz also has linked hospitals to specialisation. He has stated, first, that specialisation was a manifest necessity for medicine in the twentieth century as it was in other fields of human activity in industrial societies. He has argued that the role of expanding knowledge in the process, which was proposed by George Rosen in the 1940s, has been overemphasised.³ Rosen attributed specialisation predominantly to a growth of scientific knowledge too vast to be encompassed by any one person. Doctors focussed on narrowing fields of interest; when a sufficient number shared that interest they created a structured organisation, a specialty.⁴ Weisz believes, however, that specialties arose because doctors desired to expand knowledge. To achieve that, they needed hospitals with their stable institutional structures and administrative resources. In them doctors had access to large numbers of patients, categorised according to their disorders, of whom they could make empirical observations and add to their expertise in their special fields.⁵

Rosemary Stevens has taken a wider view of specialisation, arguing that it was a social process driven by personal, economic, organisational, and political agendas as much as by professional aspirations and power structures. She has stated that the role of nonmedical forces in specialisation has become more apparent since the 1940s when the powers of physicians to alter the course of human disease increased tremendously—for example, with antibiotics. Before then, when medicine was barely efficacious, specialisation appeared an end in itself.⁶ Many of the social processes discussed by Stevens were associated with increasing affluence and better education. People in western societies became more aware of health matters and developed an appreciation of the benefits of medical science. They acquired faith in expertise in all walks of life and recognised the benefits of specialisation which they associated with excellence and efficiency. People came to believe that access to high quality medical services was a social right.⁷

Sidney Sax noted similar attitudes specifically in Australia. After World War II, people became generally better paid and became better informed about health matters. They sought higher quality health care and began to voice their concerns as individuals and through pressure groups—the development of the belief in health care as a basic human right.⁸ Evan Willis also has argued that nonmedical factors were important in determining how medicine evolved in Australia through the first half of the twentieth century. He stated that despite their positions of authority, doctors were always constrained in the health systems by political, social, and economic forces.⁹

In Australia many large public hospitals were established by philanthropists in the latter half of the nineteenth century. At first they offered mainly shelter and support to sick, indigent people who could not be cared for at home. In that first phase of development, hospitals were governed by boards of trustees elected by benevolent subscribers, who were the donors of funds to the institution. The trustees possessed complete authority, including the control of admissions. During the next phase, which lasted throughout the first half of the twentieth century, hospitals expanded their roles to provide medical and surgical care based on the principles of scientific medicine to people of all levels of society. The boards of trustees remained nominally in control but the real authority came into the hands of the senior medical staff. Their monopolistic possession of expert knowledge imbued them with greater power to determine hospital policies than board members and administrators lacking such qualifications.¹⁰ Doctors also possessed an authority to determine how institutional resources were used in their unassailable control of the admission, treatment, and discharge of patients. The doctors, however, had conflicting obligations affecting hospital development.

During the second part of the twentieth century hospitals lost much of their autonomy. The costs of providing advanced technical and therapeutic services increased rapidly and the state was obliged to increase its subsidies to medical facilities. In this third phase of development hospitals were forced to become more accountable to governments—and, indirectly, to society—for their use of public funds and for the quality of the services they provided. Their existing administrative arrangements were not adequate for the task and new power structures developed which, in effect, meant that hospitals became extensions of government health departments.¹¹ Recently, hospitals have lost more of their autonomy and their historical identity as a consequence of government-forced amalgamations, which have mandated, for example, the merging of women's and children's hospitals and locating special hospitals with general hospitals.

Using case studies, this article explores the evolution of two Australian public hospitals in the thirty years after the end of World War II. Advances in scientific knowledge and technology stimulated a great expansion in the range and complexity of patient services. New therapeutic agents—among them more effective antimicrobial agents, and new anti-inflammatory and antineoplastic drugs—became available. New knowledge in biochemistry and physiology permitted the measurement of the effects of disease and injury on metabolic processes. New imaging techniques improved diagnostic accuracy and new procedures in surgery and anaesthesia were introduced. By increasing their technical knowledge, these innovations enhanced the authority of doctors in hospitals. However, patients, other members of society, and governments became conscious of medical advances as well and came to expect that doctors would devote more of their physical and intellectual energies to keeping abreast of new knowledge and technology and of using them appropriately.

The institutional histories to be discussed here in the context of such changes are those of two children's hospitals. The first introduced a system of organisation new to Australia and created an institutional structure that was more accountable, and in which doctors made the best use of advances in medical science. The other children's hospital retained a relatively inefficient organisational structure dominated by medical staff, exemplifying the persistence of the earlier systems of hospital organisation. The study relies heavily on the oral histories of doctors, nurses, and administrators who worked in the hospitals. Their recollections were consistent with one another and with documentary sources. Although both children's hospitals were specialty institutions, their histories are relevant to hospital development generally in Australia, because all hospitals faced the need to come to terms with expanding scientific knowledge and technology, and with the demands of society. The pattern of organisation developed by the pioneering children's hospital would eventually be adopted by most public hospitals in Australia.

Children's hospitals are included in the category of specialty hospitals, which in western societies were created, largely, by physicians wishing to expand their knowledge and skills—ambitions often thwarted in more conservative general hospitals.¹² There were other reasons for children's hospitals. In the nineteenth century perceptive citizens were beginning to understand that sick children had special physical and emotional needs that required their separation from adults. Also, in that period children were not welcome in general hospitals because they posed risks of infection to the adult patients.¹³ Children's hospitals were established in all Australian capital cities (except Hobart) between 1870 and 1909. Up to the 1950s they followed similar courses in providing adequate but modest clinical services. Then, following the example set by one children's hospital which boldly adopted a new way of doing things, they firmly embraced the principles of scientific medicine and achieved a status equal to that of the adult teaching hospitals.¹⁴

The two hospitals featured in this article are the Royal Children's Hospital, Melbourne [RCH], established in 1870, and the Royal Alexandra Hospital for Children, Sydney [RAHC], established in 1880. They were the only children's hospitals in their respective states and were held in high regard by the public for their care of sick children. In 1945 both had about 450 acute and convalescent beds.

The Royal Alexandra Hospital for Children, Sydney

The RAHC was governed by a board of management ostensibly responsible to the government and people of New South Wales. However the real authority was held by senior doctors on the staff. The largest occupational group, the nurses, had little influence on hospital policies. In 1945 the Board had twenty-three members who were business and professional men and women prominent in Sydney society, the social mix remaining largely unchanged from the 1880s to the 1970s.¹⁵ To make decisions on hospital policies, the board members depended on expert advice from the medical staff association, which was the corporate body representing the honorary medical staff. Until the 1970s, most Australian hospitals had similar bodies, which were the main sources of expert advice to their respective hospital management boards or committees.¹⁶

In the RAHC up to the 1970s, doctors had exceptional levels of influence. In 1945, for example, three of the board members were doctors elected in their own right; they included the president (presidents were doctors from 1904 to 1970) and one of the two vice-presidents. There were another two doctors with voting rights, nominated by the medical staff association. The key decision-making body—the finance committee of six—included two doctors, the president, and the vice-president.¹⁷ Despite the fact that these physicians endorsed the aims of the board to create a major paediatric centre, they had serious conflicts of interest because they were honorary medical officers who also were in private practice, which necessarily required a considerable investment of their time and energy because it was their only source of income. Many of them were deeply involved in building their professional careers. In addition, they were part of a medical staff association, which at times held views contrary to those of the board. Many also were members of the main medical professional group in Australia, the British Medical Association (BMA): some were council members and office holders of the New South Wales Branch, which was firmly opposed to any change in the long-standing role of honoraries in public hospitals. However honourable their motives were, physicians found themselves in awkward situations when, in their position as Board members, they participated in policy development, particularly regarding medical staffing.

This management predicament is exemplified by Dr T.Y. Nelson, who joined the honorary staff in 1923, became a senior surgeon in 1944, and was made an emeritus consultant in 1955. He represented the Medical Staff Association on the Board of Management from 1937 to 1939 and, in 1949, was independently elected to the board. He was vice-president from 1959 and president from 1966 to 1970.¹⁸ Nelson held strategic positions in the BMA (New South Wales branch): he was councillor from 1947 to 1965, president in 1954/55, and secretary from 1957 to 1965. From 1949 to 1965 he was a member of the BMA Medical Politics Committee, which dealt with the relationships between the medical profession, governments, and public hospitals. He was also a member of the Hospitals Committee (from 1951; chairman from 1953 to 1965), which repeatedly opposed any changes to the existing honorary system.¹⁹ Other honoraries, from time to time, held positions similar to Nelson. A medical superintendent complained that many had a greater loyalty, and contributed more, to the BMA than to their own hospital.²⁰ His views coincided with those of authorities on hospital administration who advised against medical staff having voting rights on governing boards of hospitals because both sides risked being compromised.²¹ The doctors' motives were largely ideological. From the early 1900s, many feared government intervention in health and hospital matters and, sometimes, nationalisation of the profession.²² They believed that a refusal to accept payment for services in public hospitals and the retention of the honorary system would preserve their independence and resist an insidious trend towards socialised medicine.²³

In the early post-war period, the doctors' attitudes placed the hospital in a difficult situation. One might have expected that the Board of Management would have urgently debated how it was going to respond to the challenges of emerging medical science. That would have involved, necessarily, an examination of medical organisation. A number of hospitals in the western world, principally in Germany and the United States, could have provided models. The German approach was unlikely to be successful because it was too authoritarian but the model developed in the United States offered a possible scheme.²⁴ Early in the twentieth century, William H. Welch established a new system of medical organisation in the Johns Hopkins Hospital Medical School in Baltimore. He wanted to establish a prestigious scientific institution offering first-class medical care and was convinced that this only could be realised by employing physician/scientists who could devote all their professional time to the hospital, free from the distractions of private practice. Doctors would also have managerial roles. Despite the opposition of a medical profession dedicated to free enterprise and fee-for-service medicine, Welch recruited full-time salaried medical officers in most of the major specialties. Other American hospitals adopted the Baltimore model, contributing to the pre-eminence of the United States in scientific medicine in the twentieth century.²⁵ In Australia, however, doctors rigorously opposed the employment of salaried senior medical staff.

Up to the 1970s, the senior doctors in RAHC were honorary medical officers.²⁶ They were appointed by the Board of Management but were not employees in the usual sense. Their obligations to the hospital were not defined, because they did not have formal contracts. Their duties were determined by custom and their work largely self-regulated. They did not have to account for the quality of care they provided. Politicians and the medical profession accepted that honoraries, by virtue of their position and status, provided appropriate services.²⁷ In their relative independence of board direction, honoraries enjoyed privileges not available to other staff members. In their clinical work, doctors also acted independently. There was no hierarchical medical structure which monitored or controlled their actions.

Despite their differences, the hospitals and their honoraries had common areas of interest. The hospital needed physicians to provide skilled patient care and for expert advice on medical management. Rosenberg has observed how medical careers were closely integrated into the daily work of hospitals and that the process was of fundamental importance to the development of American institutions.²⁸ Doctors needed the hospitals for their patients and for services and facilities such as nursing, operating theatres and investigational departments. Doctors intent on specialisation needed the hospital for access to patients, as Weisz has noted.²⁹ Hospitals were the workshops in which doctors enhanced their skills and established their reputations as experts in their chosen fields. In hospitals honoraries advanced their careers in private practice by demonstrating their clinical prowess to their colleagues and medical students, thereby attracting patient referrals. An ethical system of self-promotion was valuable for specialists in Australia because they were consultants: they treated only patients referred by other doctors.

Before the 1950s, honoraries in RAHC spent relatively short periods in the hospital—perhaps six to eight hours each week in ward rounds, outpatient departments, or operating theatres, often supervising the junior resident staff. After that time, there were pressures to expand their roles. However, while some were unwilling to change their patterns of work, some were judged to be ill-equipped for the new era because they were unscientific and not interested in adding to their knowledge.³⁰ Others, however, were ambitious, and wished to contribute to building a children's hospital like those of Britain and the United States. They wanted to advance their professional careers as consultant paediatricians and to establish paediatrics as a legitimate specialty in Australia.³¹

The RAHC Board had no firm plans for the future of the hospital. Therefore, in 1946 and 1947 a number of enterprising honoraries took the initiative. They established consultative clinics in cardiology, respiratory diseases, gastroenterology, and epilepsy which were, at first, limited in scope. In them the doctors broadened their experiences and provided expert advice to their colleagues.³² These moves support the contention of Weisz that specialisation was to a large extent driven by a collective desire to expand, rather than to compartmentalise, knowledge.³³ The cardiac clinic provided an example of medical expansionism. In the United States and Britain, there had been major advances in the treatment of infants and children with congenital heart disease. Their lives could be extended by new surgical procedures, with tolerable risks. Paediatric cardiology represented the western tradition of progress in medicine. New knowledge and technology created investigative and therapeutic processes which offered a capacity to operate on a critical organ system.³⁴

The treatment of congenital heart disease was complicated. Before operating, the surgeon needed to know the nature of the anatomical abnormality and the functional disturbances in the circulation of the blood to the lungs and the body. This required other experts and much specialised equipment. A physician–cardiologist and a radiologist were needed to make a diagnosis, using procedures such as cardiac catheterisation and angiocardiography. The surgeon and the anaesthetist conducted the operation with the support of technicians to manage the supporting heart–lung machine. Special nurses were needed for after-care. A coordinated team, available at all times to deal with emergencies and routine cases, was essential for successful outcomes.

The RAHC agreed to commit substantial resources to the new cardiac clinic, which was at first staffed by honorary physicians and surgeons. As the numbers of patients requiring operations increased they found it difficult to cope, despite exceptional efforts, because the work was time-consuming and demanding. The board might then have appointed salaried specialists but the medical staff association opposed such positions. As a compromise a paid sessional cardiologist was recruited. This position was tolerated by the honoraries because no one possessed the necessary technical skills. However, the cardiologist was restricted to diagnostic procedures, to prevent his competing with other paediatricians. Anaesthesia also posed problems; for cardiac surgery anaesthetists with special experience were needed. An operation might last many hours, which created difficulties for doctors who also had to earn their livelihood in private practice. The medical staff association and the hospital were eventually forced to agree to the employment of another group of specialists, but only in a sessional capacity.³⁵

The problems of managing chronic lung disorders stimulated several physicians, in 1946, to set up a respiratory committee, which established a consultative respiratory clinic to improve the treatment of bronchiectasis and cystic fibrosis. For the diverse skills needed they invited surgeons; gastroenterologists; and ear, nose, and throat specialists to join them—as well as dieticians and physiotherapists—in another team approach to medical care.³⁶ For acute respiratory problems new strategies also were necessary. Disorders such as croup, diphtheria, asthma, and respiratory failure often presented as life-threatening emergencies requiring expert assessment and treatment, and new approaches were becoming available. The respiratory committee first wrote protocols for the resident staff to help them better manage these problems. The medical staff association then recommended that the board increase the establishment of registrars, the resident doctors training to be paediatricians, to improve the quality of emergency care. Experienced senior registrars, and particularly the Chief Resident Medical Officers (CRMO) began to act as quasi staff specialists, making urgent clinical decisions previously made by the honoraries, who nevertheless remained nominally in charge. The CRMOs also took on other responsible roles. Being readily available to hospital management, they were asked for advice on matters concerning medical organisation.³⁷ The changes were tolerated by the honoraries; after all, they had little choice. But the precedents established meant that salaried specialists would eventually be employed.

The logistics for managing complicated clinical tasks also came under scrutiny because it was becoming unpractical to treat seriously ill and injured children dispersed in the general wards. In 1965 the respiratory committee recommended that special care be centralised in a dedicated eight-bed ward where experienced nurses could be more expeditiously provided, as well as equipment which was often bulky, technically sophisticated, and expensive.³⁸ The concept of intensive care evolved. Seriously-ill patients and those with special problems were moved to the new area from wards which honoraries had previously controlled. At first, the honoraries continued to manage these patients, but, nevertheless, the stage was set for the employment of medical staff trained in intensive care. However, it was not until 1976 that RAHC appointed a salaried intensive care physician.³⁹

These examples illustrate how the honorary medical officers responded to the imperatives of scientific medicine by setting up advisory clinics and committees. Eventually, there were twenty-three such corporate bodies. They included an oncology clinic, to coordinate cancer therapy for which combined medical/surgical treatment was coming into vogue, and clinics for allergies and the management of pink disease. There were committees to advise on tetanus and hospital infections, and to formulate policies on the nutrition of children in hospital and on adolescent care. Committees helped develop the medical library and improve the quality of medical records.⁴⁰ Physicians who had attached great value to working as independent individuals in both hospitals and private practice previously, now worked in groups—a new approach to solving hospital problems. Committee work was onerous, but was the price the honoraries paid to retain their authority.

In 1964 hospital administrator, Dr. John Fulton described the committee system as inefficient, and asserted that it would be better for it to be replaced by 'a hard core of full-time clinicians with administrative roles.'⁴¹ He noted that there were 131 honorary medical officers in RAHC and that, while they performed useful work, they had many shortcomings. They spent too little time in the hospital, they gave priority to their private work, and travelling to and from the hospital was time-consuming. They were often unpunctual in attending their hospital duties, thereby disrupting the work of the operating theatres and wards. Many were so busy that they could not keep up with current medical knowledge. There was no way of dealing with those who did not provide the services expected of them. Honoraries were not hospital-minded; their main professional interests lay elsewhere.⁴² However, the administrator could not change the situation, despite being a main figure in some major changes that had been enabled. Up to the middle of the twentieth century, many large Australian hospitals lacked management of substance. The most senior hospital executive was usually a secretary/manager who was responsible for financial matters and for controlling the house-keeping services. There was a matron for the nursing services and a medical superintendent in a relatively junior post, who supervised the resident medical staff. None had authority over the honoraries. However, in the second half of the century matters changed with the appearance of hospital administrators with professional qualifications in management (some also had medical qualifications) which gave them a status equal to that of the senior medical staff.⁴³

The administrator of the RAHC from 1923 to 1949 was Dr. S.W.G. Ratcliff, who had graduated in medicine in 1916. He was a traditional manager who did not intrude on medical policy making.⁴⁴ In 1949 Dr. Fulton, as one of the new type of career medical administrators, was appointed chief executive officer (CEO). He had had an impressive career in medical administration in Tasmania and in the Royal Australian Air Force during World War II.⁴⁵ He wanted RAHC to be a first-class children's hospital with full-time salaried staff specialists responsible for the management of the main clinical departments.⁴⁶ However, Fulton's position was administratively difficult. In commercial organisations, employees were responsible to the CEO who provided the channel of communication to the governing body. In RAHC the honorary medical staff had direct access to the Board through their elected representatives and through their colleagues on the Board and therefore often by-passed the CEO. Fulton accepted that doctors provided advice to the Board, but disapproved of their massive influence because they had vested interests which interfered with the Board's responsibility to the people of New South Wales.⁴⁷ However, Fulton was unable to change medical staffing in his hospital, in contrast to the hospital discussed below.

The RAHC honoraries gradually realised that they would not be able to provide the services that they and the people of New South Wales expected. They saw the need for a core, at least, of full-time specialists; but it was not until 1976 that staff specialists in medicine and surgery were appointed.⁴⁸ There were, however, other circumstances inducing changes to public hospitals. In 1974 the Federal Government introduced Medibank, a national health plan which included provisions for the remuneration of all doctors working in public hospitals. The honorary system came to an end and the doctors accepted formal contracts with hospitals as visiting medical officers.⁴⁹ Governments, representing Australian society, would now determine, to a much greater extent, hospital policies.

The growing public interest in hospital organisation and medical care was an additional factor in the emerging changes in hospital organisation. For example, a consumers' group representative accused the RAHC of lacking public accountability, describing the Board as elitist, intransigent, and unresponsive to well-intentioned advice from non-medical individuals and community groups because it was unduly influenced by the senior medical staff.⁵⁰ Other Australian public hospitals similarly denied consumer and societal participation in their planning processes.⁵¹ From the 1960s onward, increasing numbers of community-based hospital interest groups arose. They included the Association for the Welfare of Children in Hospital, which successfully persuaded hospitals across Australia to liberalise their previously restricted hours of parental visiting.⁵² Patient support groups evolved. One of the first in the RAHC was established by the parents of children who had been patients in the cardiac surgery unit. They supported the parents of other children undergoing surgery and regularly met with the surgeons and nurses of the service. They discussed their experiences and provided information, which influenced patient care. These groups would not have been tolerated previously by either the hospital board or the medical staff.⁵³

The RAHC was slow to institute change to deal efficiently with the pressures of scientific medicine and slow to acknowledge that the citizens of New South Wales wished to be involved in decisions about hospital services that were important to them. Much of the resistance to change came from the senior medical staff, who, although well-intentioned towards their hospital and their patients, were motivated by their desire to preserve their professional status and to maintain the independence of the medical profession. In another children's hospital in Australia, changes in attitudes to public responsibility occurred much earlier.

The Royal Children's Hospital, Melbourne

In 1945 the Royal Children's Hospital, Melbourne (RCH) was much like Sydney's RAHC. The senior medical staff were honoraries, with only a few practising exclusively in paediatrics; most were general practitioners, adult physicians, or surgeons with an interest in children's diseases. In Victoria, as in New South Wales, paediatrics was a barely viable specialty. Physicians were conservative: they wished to return to pre-war conditions despite the opportunities offered by the expansion of scientific medicine.⁵⁴ An important difference between the RCH and the RAHC was in the authority and enterprise demonstrated by the RCH Committee of Management, which from the mid-1930s had maintained a bold vision for a first-class paediatric hospital for the children of Victoria.⁵⁵

The first RCH Committee of Management was formed in 1870 by a group of seventeen philanthropic women from wealthy Victorian families prominent in business, politics, the professions, and the pastoral industry. There were no physicians among the members. The committee was self-selecting and self-perpetuating, with new members recruited by existing members. Membership required the approval of hospital subscribers at the annual meetings, but this was a formality. The arrangement created a cohesive group of powerful and influential women, which endured until the 1980s.⁵⁶

The president of the RCH from 1933 to 1954 was Ella (later Lady) Latham. She had her own views about the future of the hospital but was prepared to seek external advice, unlike her counterparts at the RAHC. Ella Latham had close ties to the University of Melbourne, where from 1935 to 1941 her husband was deputy chancellor and then chancellor. She was acquainted with senior members of the Faculty of Medicine, and accepted that if hospitals wished to become advanced scientific institutions, like those in the United States, they should build links to universities. In the late 1930s she was told by her academic and political contacts that a war with Germany and Japan was inevitable and that the existing scientific contacts with Britain and the United States would be disrupted.⁵⁷ She understood that first-class teaching hospitals would be essential if Australia was to become independent in training doctors for the specialties and in medical research.⁵⁸

Persuasive authorities from outside the hospital undoubtedly helped the members of the Committee of Management of RCH to formulate their ambitious plans and strengthened their resolve to introduce and sustain radical changes in hospital organisation. In contrast, the RAHC appears to have received little external advice. Although the institution was a teaching hospital of the University of Sydney, there were no university representatives on the Board.⁵⁹

In 1940 the RCH Committee of Management endorsed a plan for the hospital to become a centre of knowledge, research, and teaching in paediatrics.⁶⁰ There were no opportunities for implementing these plans, however, until the end of World War II, when the committee members—ignoring the negative views of the medical staff, which held opinions similar to those at the RAHC—went elsewhere for expert advice.⁶¹ They established a new body, the Medical Advisory Board, on which the University of Melbourne had two representatives—the vice chancellor and the dean of the Faculty of Medicine. The Medical Staff Association objected, but without effect.⁶² In 1946 the committee further reduced the influence of the medical staff when the advisory board was expanded to include seven members of the Committee of Management, four representatives of the university, and only three honorary medical officers.⁶³ This body played a central role in determining the future of the hospital because it was responsible, amongst other roles, for making recommendations on appointments to the senior medical staff—previously the privilege of the medical staff council.

The university representatives, particularly Professor Douglas Wright (professor of physiology), who was a member of the Medical Advisory Board from 1947, urged the hospital to foster high academic standards and engage in formal research.⁶⁴ Wright had impressive credentials in scientific medicine and university governance. During the period of post-war reconstruction he was involved, with Dr H.C.Coombs and Sir Howard (later Lord) Florey, in negotiations with the Federal Government on proposals for a national institute of medical research. Wright advocated that all the teaching hospitals of the University of Melbourne should have research units.⁶⁵ He was disappointed when the RCH elected to concentrate on programmes of clinical, rather than basic, research. The committee was probably influenced by Dr Reginald Webster, a full-time hospital pathologist from 1914 to 1947. Webster, in association with his routine work, conducted research in many fields including poliomyelitis, meningitis, and tuberculosis. The decision to establish clinical research earned the approval of the medical staff, who could see that it would directly benefit their care of patients.⁶⁶

In the late 1940s the Committee of Management of the RCH began to implement their plans, of which the central component was the employment of paediatric physicians and surgeons who would devote themselves full-time to the hospital and manage key clinical departments, following the organisation of prestigious university hospitals of the United States. Part-time salaried doctors would also be needed for clinical services. The payment of clinical specialists was a radical step for an Australian hospital, particularly one clearly visible to the conservative medical establishment of a state capital such as Melbourne. Only one other hospital in Australia, the Royal Newcastle Hospital, had full-time salaried clinical staff (from the late 1940s onward) but that institution was in a provincial city and largely ignored until the British Medical Association decided in 1960 that it might pose a socialist threat.⁶⁷

RCH appointed a medical director, Dr. Vernon Collins, to create a management structure that would ensure that the Committee of Management remained the supreme authority in the hospital. Collins was a medical administrator and paediatrician. He had been medical superintendent from 1937 to 1939, when it was a relatively junior post. During World War II he had worked in London as a physician with the Emergency Medical Service (EMS), which gave him an insight into alternate systems of medical staffing. He also was aware of the organisation of the Johns Hopkins Hospital.⁶⁸ The EMS recruited physicians and surgeons into a salaried hospital service anticipating that air raids would cause many civilian casualties. Collins observed how doctors who had previously been honoraries with no management responsibilities adopted a broader approach to health services. He saw how eagerly they participated in planning improvements in the quality and efficiency of hospital systems.⁶⁹ In Britain, until the National Health Service was established in 1948, the policies of large teaching hospitals were largely determined by honorary medical officers through their influence on boards of trustees. For British honoraries, as Brian Abel-Smith has observed, 'the hospital was a means to an end, the end being an adequately remunerated private practice.'⁷⁰ It is not surprising that there were similarities between British and Australian hospitals, given that, up to the 1970s, hospital organisation in Australia was derived largely from pre-war British models.

In 1948 Collins took up his new position at the RCH, which included a clinical role as senior physician.⁷¹ The honorary system was abolished in 1951 and the visiting medical staff—many, previously honoraries—were paid sessional fees for their clinical duties.⁷² By early 1953 there were full-time or near-full-time medical officers in charge of the major clinical departments of the hospital. Individual department directors would take responsibility for tasks that committees undertook at the RAHC. The directors were responsible to the medical director, who in turn answered to the Committee of Management. The clinicians had contractual obligations to the hospital to provide the services for which they were employed. Doctors could contribute to hospital planning through their departmental director and through the medical staff association, but their advice was always weighed against that of the Medical Advisory Board. The sessional medical staff received sufficient remuneration to ensure that their private practices were not valid competitors for their time. The arrangement was useful for young paediatricians beginning in practice and encouraged the recruitment of new trainees for paediatrics, further strengthening the new specialty and the hospital.⁷³

The Victorian Hospitals and Charities Commission was impressed by the plans of the hospital to employ a mix of medical staff—both full- and part-time salaried doctors as well as paid sessional visiting medical officers—declaring it more efficient than the honorary system.⁷⁴ The Commission continued to meet the costs of the expanding budget while gaining an increased supervision of the hospital budgets.⁷⁵ The RCH also had substantial funds available from charities, particularly the annual Good Friday appeal, to support its new enterprises.⁷⁶

During the post-war period, large Australian hospitals increasingly appreciated that research was important for their development as scientific institutions. Previously, however, Australian teaching hospitals had been slow to become involved in clinical and laboratory-based research. They followed the pattern of their counterparts in Britain, where the senior medical staff gave priority to ensuring excellence in patient care and research was slow to develop, again with some notable exceptions. The United States, however—influenced by German models—had made laboratory-based research a vital component of university hospitals since the late–nineteenth century. There, research activity in hospitals greatly expanded following the 1912 publication of the Flexner Report, which emphasised the importance of science in medical education.⁷⁷

In 1947 the RCH established a Clinical Research Unit, with Dr. Howard Williams as director. Like the medical superintendent, he was granted high status in the hospital, which meant, in the prevailing medical conventions, that he became a senior physician.⁷⁸ The granting of clinical privileges to salaried staff was made despite the opposition of the honoraries and the Victorian branch of the BMA, which held that paid medical staff should not be allocated beds in the hospital because they might compete unfairly with honoraries.⁷⁹ Williams established programmes in respiratory disorders, gastroenterology, and fluid and electrolyte metabolism, which produced information of immediate value to other paediatricians in their care of patients.⁸⁰ Many of the visiting doctors established research projects in their areas of specialisation, with the support of the Medical Director and the Committee of Management.⁸¹

In contrast, the RAHC was slow to embark on organised research despite the establishment, in 1948, of a chair of child health—the first in Australia.⁸² The chair was funded by the Commonwealth Department of Health and the University of Sydney, largely to foster paediatric education. The professor, Lorimer Dods, was a respected clinician, but he initiated little research of relevance to his clinical colleagues. In any case, the atmosphere of the RAHC was not conducive to clinical research because the honoraries had little time due to their commitment to their private practices.⁸³

The task of the Committee of Management at the RCH in implementing the new scheme became easier because of the appointment of new paediatricians. At the end of World War II, older honoraries retired and were replaced by six younger paediatric physicians who had trained in Australia and Britain before the war and had returned from military service ready to establish careers in private practice, to join the hospital staff, and to engage in research. They were ambitious and supported the introduction of the new regime in the medical staff association.⁸⁴

Initially, the RCH plan was opposed by the BMA (Victorian branch).⁸⁵ However, the new scheme was not resisted as much as might have been expected, perhaps because paediatrics was at an early stage of development and was a poorly-remunerated specialty. It is also possible that there was a perception that treating sick children was done out of altruism. In any case, it would have been difficult to overcome the determination of the Committee of Management to implement their plans. As well, Collins was a powerful agent for promoting change. He was a skilled negotiator with a rational approach to hospital development and strong diplomatic skills, which usually disarmed resistance.⁸⁶ At the RAHC, the board of Management was dominated by conservative medical members, and Fulton, who held similar ideas to Collins on hospital organisation, was not strong enough to convert the Board to his ideas. He could not change the attitudes of the honoraries, with whom he sometimes had difficulty communicating.⁸⁷

Collins had advantages over Fulton in dealing with physicians. Although Fulton possessed a medical degree and was well-qualified in medical administration, he did not have credentials in clinical paediatrics and it is possible that he was therefore viewed with suspicion by the honoraries. Physicians in Australian hospitals feared the appointment of full-time medical directors or chiefs of service who might challenge their authority and diminish their status.⁸⁸ Later, there would be successful administrators without clinical standing, but it was valuable for the RCH—in a pioneering phase of hospital development—to have in Collins a medical director who had much in common with his medical staff, many of whom had been his clinical colleagues.

One might ask why the RCH differed from the RAHC in its evolution. They were similar hospitals in 1945. Their boards of trustees came from similar social backgrounds. Both boards were self-selecting and self-perpetuating, despite the nominal requirement for elections. Because of their associations with the elite, one might have expected that the trustees in both hospitals would have sided with the physicians who shared their social background. Both boards wished to create first-class medical institutions, yet they responded differently to the challenges of scientific medicine and the changing social environment. The course followed by the RAHC may be attributed to the ideological views of the doctors and their influence on the Board of Management, a situation found in most public hospitals in Australia in varying degrees (but not in Queensland, because the state government there abolished the honorary system—deemed inefficient—in the 1940s and assumed complete control of public hospitals. A full-time salaried specialist system did not eventuate until later).⁸⁹ The staffing of hospitals with honorary medical officers was criticised by Dr. Malcolm MacEachern, an American authority commissioned to report on the state of hospital care in Australia in 1953. Amongst other matters, he concluded that the organisation of the medical staff in many large hospitals was unsatisfactory. A community served by a hospital was disadvantaged when all specialist doctors on the staff had equal status and had equal access to the administration. He declared that hospitals would be more efficient if they had chiefs or heads controlling each medical or surgical service, under a governing body possessing complete authority.⁹⁰

The RCH Committee of Management undoubtedly possessed complete authority, a situation that Howard Williams attributed to the determination of the Committee of Management, led by Lady Ella Latham. He observed that she possessed a strong social conscience and came from a family dedicated to public service. Under her guidance the RCH produced a unique plan for a broad field of health care, at a time when, as J.C.H. Dewdney stated, there were no national or state health planning processes in place.⁹¹ As well as her dominant role at the RCH, Lady Latham also founded the Victorian Society for Crippled Children. Her husband, Sir John Latham, was a lawyer, a parliamentarian, and later chief justice of the High Court of Australia.⁹² One can speculate that Lady Latham was a strong and formal president, very conscious of the role and status of her Committee of Management as the governing body, to which the doctors were always answerable irrespective of their clinical and advisory roles.

Was the RCH a better hospital than the RAHC? There were no objective means available to measure hospital performance. Both hospitals were highly respected by the public and provided services which met the expectations of the societies in which they were placed. It was a period when public hospital performance was rarely questioned. However, prominent paediatricians on the staff of the RAHC have acknowledged that, both in research and in the development of services based on the principles of scientific medicine, the RCH was far ahead of the RAHC, a situation they attributed to the presence of the full-time medical staff. In addition, if imitation is an indicator of success, then the RCH again was superior. Other children's hospitals in Australia, including eventually the RAHC, adopted the RCH model.⁹³

Conclusions

The Royal Children's Hospital in Melbourne was a pioneer in Australia in bringing a cultural change to hospitals, creating an organisation in which a board of trustees, in their designated role of representing the society in which the hospital was placed, overcame the long-held authority of the medical staff and asserted control of the hospital. The RCH anticipated changes that would take place progressively in other Australian hospitals following the introduction of Medibank and the increasing intervention of governments in hospital affairs. At the Royal Alexandra Hospital for Children in Sydney, as in many other Australian hospitals, the medical staff effectively controlled the hospital and maintained its isolation from those who might justifiably have wished to contribute to policy development. The physicians' ideologically-driven efforts to retain their long-held status delayed the introduction of scientific medicine in the hospital. This study supports the contention of Stevens that hospital development was governed by many social and medical forces.⁹⁴ In Australia, as the twentieth century progressed, social forces predominated.

Notes

^1. A short selective list of histories includes books by professional historians. A broad, succinct history of an elite civic institution with a powerful medical staff intent on embracing expanding scientific knowledge is K.S. Inglis, Hospital and Community: A History of the Royal Melbourne Hospital (Melbourne: Melbourne University Press, 1958). Also, Peter Yule has written a long and detailed history which includes references to many personalities, a common practice in commemorative histories—see Peter Yule, The Royal Children's Hospital: A History of Faith, Science and Love (Sydney: Halstead Press, 1999). Histories also have been written by hospital staff, mainly doctors and nurses, who may give their own slant to a story, for example: Muriel Knox Doherty, The Life and Times of Royal Prince Alfred Hospital, Sydney, Australia, edited by R. Lynette Russell (Sydney: NSW College of Nursing, 1996); J. Estcourt Hughes, A History of Royal Adelaide Hospital (Adelaide: Royal Adelaide Hospital, 1982). There also are histories of regional hospitals: Anthea Hyslop, Sovereign Remedies: A History of Ballarat Base Hospital 1850s to 1980s (Sydney: Allen and Unwin, 1989); Susan Marsden, The Royal A Castle Grand, a Purpose Noble: The Royal Newcastle Hospital 1817–2005 (Newcastle, Australia: Hunter New England Area Health Service, 2005). Special hospitals also have been described, for example, notable not only because it deals with the health problems of women and prevailing social issues, but also in making extensive use of patients' recollections, is Janet McCalman, Sex and Suffering: Women's Health and a Women's Hospital, The Royal Women's Hospital, Melbourne, 1856–1966 (Melbourne: Melbourne University Press, 1998). (Additionally, for references pertaining to children's hospitals see note 14 below.)
The problems faced by authors in attempting to give due weight to the many issues involved in hospital development are discussed in, for example, Geoffrey Rivett, "Hospital Histories," Social History of Medicine 6, no. 3 (1993): 429–37.

^2. Charles Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York: Basic Books, 1987; Baltimore: Johns Hopkins University Press, 1995), 9, 175, 189.

^3. George Weisz, "The Emergence of Medical Specialization in the Nineteenth Century," Bulletin of the History of Medicine 77 (2003): 536–75.

^4. George Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology (New York: Froben Press, 1944).

^5. Weisz, 536–75.

^6. Rosemary Stevens, American Medicine and the Public Interest A History of Specialization (Berkeley: University of California Press, 1998), 529, 530.

^7. Rosemary Stevens, Medical Practice in Modern England The Impact of Specialization on State Medicine (New Haven: Yale University Press, 1966), 3, 6; Edward Shorter, "The History of the Doctor–Patient Relationship," in Companion Encyclopedia of the History of Medicine, edited by W.F. Bynum and Roy Porter (London: Routledge, 1993), 796; Joel D. Howell, Technology in Hospitals Transforming Hospitals in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995), 30.

^8. Sidney Sax, Medical Care in the Melting Pot: An Australian Review (Sydney: Angus and Robertson, 1972), 10, 11.

^9. Evan Willis, Medical Dominance: The Division of Labour in Australian Health Care (Sydney: Allen and Unwin, 1989), 224, 225.

^10. James A. Gillespie, The Price of Health Australian Governments and Medical Politics 1910–1960 (Sydney: NSW University Press, 1988), 16.

^11. Anne Crichton, Slowly Taking Control: Australian Government and Health Care Provision 1788–1988 (Sydney: Allen and Unwin, 1990), 26–30.

^12. Lindsay Granshaw, "'Fame and Fortune by Means of Bricks and Mortar': The Medical Profession and Specialist Hospitals in Britain, 1800–1948," in The Hospital in History, edited by Lindsay Granshaw and Roy Porter (London: Rutledge, 1990), 199–220; Sydney A. Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1980 (Berkeley: University of California Press, 1988), 42–3, 151–2.

^13. Elizabeth M.R. Lomax, Small and Special; The Development of Hospitals for Children in Victorian Britain (London: Wellcome Institute for the History of Medicine, 1996).

^14. H.E. Williams (paediatrician, RCH), correspondence and interviews with author, Melbourne, 1995, 1998; D.G. Hamilton (paediatrician, RAHC), correspondence and interview with author, Sydney, 1998; D.G. Hamilton, Hand in Hand: The Story of the Royal Alexandra Hospital for Children, Sydney (Sydney: John Ferguson, 1979); Yule, The Royal Children's Hospital; H.E. Williams, From Charity to Teaching Hospital: Ella Latham's Presidency 1933–1954 (Melbourne: The Royal Children's Hospital, 1989); Margaret Barbalet, The Adelaide Children's Hospital, 1876–1976 (Adelaide: Griffin Press, 1976); Julie Marshall, Starting with Threepence: The Story of the Princess Margaret Hospital for Children (Perth: Freemantle Arts Centre Press, 1996); Peter Hall, Royal Children's Hospital, Brisbane: A Century of Care (Brisbane: Royal Children's Hospital, 1978).

^15. Royal Alexandra Hospital for Children Incorporation Act, No.8. 1906, which provided for the annual election of a president, two vice-presidents (one female), a treasurer, a secretary, and nine female and seven male members. Almost half the board members retired annually but were eligible for re-election by the benefactors and the members (those who had subscribed not less than one pound a year). There also were several life-members. Elections were rarely contested and retiring members were replaced by board nominees. There were two representatives of the senior medical staff elected by the staff. Salaried staff were not entitled to a seat. Trevor Ward (a senior administrative officer in RAHC), interview with author, Sydney, 12 May 1998.

^16. Edward Stuckey, "The staffing of public hospitals," Medical Journal of Australia 1 (1961): 890–4. Stuckey was, at this time, president of the NSW branch of the BMA.

^17. RAHC, "Annual Report 1945–46," RAHC medical library, Sydney.

^18. A. McReady, "Obituary of Thomas Yeates Nelson," Medical Journal of Australia 2 (1971): 278–80.

^19. BMA ( NSW Branch) Council, "Politics and Hospitals Committees Reports," Records of AMA (NSW branch), File minute books, Bay 2E12, Mitchell Library, Sydney.

^20. W. Grigor (senior paediatrician RAHC), interview with author, Sydney, 30 June 1998.

^21. Malcolm T. MacEachern, Hospital Organisation and Management (Chicago: Physicians' Record Co., 1935), 80.

^22. J.C.H. Dewdney, Australian Health Services (Sydney: John Wiley, 1972), 21, 70, 34; Crichton, 74, 204.

^23. BMA, "Minutes, Medical Politics Committee, 21 February 1961," "Minutes, Hospital Committee, 22 September 1964," "Minutes, Hospital Committee, 23 November 1965," Records of AMA (NSW branch), File minute books, Bay 2E12, Mitchell Library, Sydney.

^24. Abraham Flexner, An Autobiography [I Remember, 1940] (New York: Simon and Schuster, 1960), 69, 70. Flexner visited medical schools in the U.S., Canada, Britain, and Germany early in the twentieth century before writing his report on U.S. medical education which led to a dramatic improvement in U.S. hospitals and medical schools. He asserted that Anglo-American doctors would not tolerate the pyramidal medical managerial structure found in German hospitals.

^25. Simon Flexner and James Thomas Flexner, William Henry Welch and the Heroic Age in American Medicine (Baltimore: Johns Hopkins University Press, 1993).

^26. Hamilton, correspondence and interview. The resident medical officers were salaried, but they posed no threat to the honorary system.

^27. Ibid.

^28. Rosenberg, 168.

^29. Weisz, 536–75.

^30. Hamilton, correspondence and interview.

^31. Ibid. See also R.G. Evans, "Paediatrics in NSW, 1945 to 1965" (PhD thesis, University of Newcastle, 2000), 1–3; Lorimer Dods, "As it was in the beginning," Australian Paediatric Journal 4 (1968): 204–8.

^32. Hamilton, correspondence and interview.

^33. Weisz, 536–75.

^34. Arthur Kleinman, "What is Specific to Western Medicine?" in Companion Encyclopedia of the History of Medicine, edited by W.F. Bynum and Roy Porter (London: Routledge, 1993), 15–23.

^35. RAHC, "Minutes, Medical Staff Association, 4 and 6 February 1948," "Minutes, Medical Staff Association, 4 August 1948," "Minutes, House Committee, 29 July and 14 December 1953," RAHC Archives, Sydney; Grigor, interview.

^36. RAHC, "Minutes, Medical Staff Association, 30 November 1945," "Minutes, Medical Staff Association, 8 February 1946," "Minutes, Medical Staff Association, 2 August 1946," RAHC Archives, Sydney.

^37. John Beveridge (previously CRMO and professor of paediatrics, University of NSW), interview with author, Sydney, 19 May 1998; Graeme Morgan (previously CRMO and paediatrician), interview with author, Sydney, 13 October 1998.

^38. Hamilton, Hand in Hand, 286.

^39. RAHC, "Minutes, House Committee, July 1965," NC088, RAHC Archives, Sydney; Hamilton, Hand in Hand, 285.

^40. RAHC, "Minutes, Medical Staff Association, 1946–62" (a series of notations in the minutes), RAHC Archives, Sydney.

^41. John Fulton, "'Changing Patterns in Hospitals': Lecture to the Resident School in Hospital Administration, University of New South Wales, 12 August 1964," File A20, RAHC Archives, Sydney.

^42. Ibid.

^43. Crichton, 145, 146.

^44. Ward, interview; Hamilton, Hand in Hand, 108.

^45. Douglas Pettinger (former medical administrator, RAHC), interview with author, Sydney, 21 March 1998; Hamilton, Hand in Hand, 172.

^46. Pettinger, interview; Vernon Collins, "Obituary of Fulton," Medical Journal of Australia, 1 (1966): 1088–9.

^47. Fulton, "Changing Patterns in Hospitals."

^48. Hamilton, Hand in Hand, 286.

^49. Crichton, 72, 73.

^50. Doris Hart, "AWCH—The Broad View: As it Was in the First Ten Years," Children in Hospital 19 (1993): 2–5.

^51. Crichton, 64.

^52. Hart, 2–5.

^53. Mr. and Mrs. Clark [pseud.] (parents of cardiac patient), interview with author, Sydney, 12 October 1999.

^54. RCH, "Minutes, Committee of Management, 6 December 1945," Committee of Management Minute Books, RCH Archives, Melbourne.

^55. John Colebatch, interview with author, Melbourne, 30 August 1999. Colebatch began his training as a paediatrician in RCH in 1935 and became a prominent paediatric haematologist.

^56. Yule, 17, 98.

^57. Colebatch, interview.

^58. Ibid.; Williams, From Charity to Teaching Hospital, 26–33.

^59. Ward, interview.

^60. Williams, From Charity to Teaching Hospital, xiii, 2, 3.

^61. Ibid., 87–92.

^62. RCH, "Minutes, Committee of Management, 6 June 1940," "Minutes, Committee of Management, 12 September 1940," RCH Archives, Melbourne.

^63. RCH, "Minutes, Committee of Management, 15 August 1946," RCH Archives, Melbourne.

^64. RCH, "Minutes, House Committee, 13 March 1947," House Committee Minute Record Book, RCH Archives, Melbourne.

^65. Peter McPhee, "Pansy" A Life of Roy Douglas Wright (Melbourne: Melbourne University Press, 1999), 72, 81.

^66. Colebatch, interview; Reginald Webster, Fifty Nine Years in Pathology and Medical Research 1914–1974 (Author, Royal Children's Hospital, Melbourne, 1974), 1–57 (copy held in History of Medicine Library, Royal Australasian College of Physicians, Sydney).

^67. R.G. Evans, "A Professor Honorarius: An Australian Experiment in Medical Administration 1939–64," Health and History 5 (2003): 115–38; BMA (NSW branch), "Medical Politics Committee minutes, 16 February, 1960," Records of AMA (NSW branch), File minute books, Bay 2E12, Mitchell Library, Sydney.

^68. Robert Southby, "Professor Vernon Collins," Australian Paediatric Journal 10 (1974): 255–7; V. L. Collins, "Medical and Paediatric Education Overseas," Medical Journal of Australia 2 (1961): 154–7.

^69. H.E. Williams, "Vernon Leslie Collins, An Appreciation," Australian Paediatric Journal 10 (1974): 255–7.

^70. Brian Abel-Smith, The Hospitals 1800–1948: A Study in Social Administration in England and Wales (London: Heinemann, 1960), 447.

^71. RCH, "Minutes, Committee of Management, 4 November 1948," Committee of Management Minute Books, RCH Archives, Melbourne.

^72. RCH, "Minutes, Committee of Management, 11 October 1951," "Minutes, Committee of Management, 22 November 1951," Committee of Management Minute Books, RCH Archives, Melbourne.

^73. RCH, "Annual Report, 1952–53," RCH medical library, Melbourne; Williams, From Charity to Teaching Hospital, 96.

^74. RCH, "Minutes, Committee of Management, 22 November 1951," "Minutes, Committee of Management, 20 December 1951," "Minutes, Committee of Management, 29 June 1953," Committee of Management Minute Books, RCH Archives, Melbourne.

^75. Yule, 272–3.

^76. Ibid., 375.

^77. Christopher C. Booth, "Clinical Research," in Companion Encyclopedia of the History of Medicine, edited by W.F. Bynum and Roy Porter (London: Routledge, 1993), 205–29; K.A. Davis, "British Pediatrics," in History of Pediatrics 1850–1950, edited by Buford L. Nichols, Angel Ballabriga, and Norman Kretchmer (New York: Raven Press, 1991), 31–7; Howard A. Pearson "Pediatrics in the United States," in History of Pediatrics 1850–1950, edited by Buford L. Nichols, Angel Ballabriga, and Norman Kretchmer (New York: Raven Press, 1991), 55–63.

^78. RCH, "Minutes, Committee of Management, 20 May 1948," Committee of Management Minute Books, RCH Archives, Melbourne.

^79. RCH, "Minutes, Committee of Management, 1 May 1947," Committee of Management Minute Books, RCH Archives, Melbourne.

^80. RCH, "Annual Reports, 1948, 1950–51, 1952–53," RCH medical library, Melbourne.

^81. Colebatch, interview.

^82. RAHC was followed later by paediatric professors in other public hospitals: Perth from 1957, Melbourne from 1959, Adelaide from 1959, and then the other medical schools.

^83. Morgan, interview; Beveridge, interview. Paediatric research slowly expanded from the 1950s; there were sufficient investigators engaged by 1967 to form a Paediatric Research Society. See D.G. Hamilton, A History of the Australian College of Paediatrics 1950–1980 (Melbourne: Australian College of Paediatrics, 1990), 35–8.

^84. Colebatch, interview.

^85. RCH, "Minutes, Committee of Management, 18 December 1945," Committee of Management Minute Books, RCH Archives, Melbourne. This document contains a report of a meeting of representatives of the honorary staff of metropolitan hospitals and the BMA.

^86. P.G. Jones, "The Second Vernon Collins Memorial Oration, 30 November 1983," Committee of Management Minute Books, RCH Archives, Melbourne;.

^87. Beveridge, interview.

^88. John. Fulton, "Problems of Medical Staff Organisation and Relationships: Notes for a Lecture to the School of Hospital Administration, University of NSW, 9 April 1963," File A20, RAHC Archives, Sydney.

^89. Crichton, 26, 28.

^90. Malcolm MacEachern, "A Report on Hospitals of Australia with Special Consideration of Teaching Hospitals," report prepared for the Federal Council of The Australian Hospital Association and the Governments of Australia, New South Wales, and Victoria, 1953, History of Medicine Library, RACP, Sydney.

^91. Dewdney, 339.

^92. Williams, From Charity to Teaching Hospital, 132–41.

^93. Hamilton, Hand in Hand; Barbalet, The Adelaide Children's Hospital; Marshall, Starting with Threepence; Hall, Royal Children's Hospital, Brisbane.

^94. Stevens, American Medicine and the Public Interest, 529, 530.

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