The Fourth of the Four Hospitals

Brian Joseph Shea, previously Director of Mental Health

This address was delivered at the third Foundation Day Ceremony held at Royal Adelaide Hospital on 8 July, 1981.

In giving this brief address the title of ‘The Fourth of the Four Hospitals’, I am indebted to Mr J Estcourt Hughes who headed the first chapter of his book A History of the Royal Adelaide Hospital with the title ‘The Four Hospitals’. In making this reference Mr Estcourt Hughes referred to the first public hospital in Adelaide, the Colonial Infirmary as the first of the four hospitals. On its several sites the Colonial Infirmary served the people of Adelaide from 1837 until 1841.

The first, or old, Adelaide Hospital – the second in the Hughes series – admitted patients for the first time in 1841 and was sited in the parklands to the north of Botanic Road and near Hackney Road. It remained the only public general hospital in Adelaide until 1856 when the Adelaide Hospital was rebuilt on its present site to the north of North Terrace and to the east of Frome Road.

With many piecemeal additions this third hospital remained standing until demolition of the buildings started in November, 1963, in preparation for the new or fourth hospital. To quote Estcourt Hughes

The fourth hospital in its complete form, is at this time, still a thing of the future, but building the first section is well advanced. This stage has been reached after much discussion about the necessity for a new Royal Adelaide Hospital, about the type of building which should be erected and about the facilities which should be provided.

It must be remembered that Estcourt Hughes wrote these words in 1966 and it is of interest that the fourth hospital even now has not reached its complete form.

The history of the various stages of development, until the year 1966, of Royal Adelaide Hospital has been so well documented by Estcourt Hughes that it would be presumptuous on my part to retrace those early days. Today I wish to comment mainly on the period 1967-77 – a mere decade in the life story of this great hospital in comparison with the 129 years of history encompassed by Estcourt Hughes in his well documented account of early developments. The decade 1967-77 has not been without its interests, however, and it was certainly a period where many millions of dollars were spent on building programmes and equipment in order to provide comprehensive up-to-date facilities for the care of patients, for the teaching of staff and students and for research activities. Staff numbers increased very substantially at this time.

This ‘boom’ period saw the occupation of the new East Wing, the completion of the new Administration, Teaching and Services Block, the opening of the new wards in the North Wing, the consolidation of the new operating theatre suites and the introduction of services in the vastly enhanced casualty and outpatient units. The building of the new nurses’ home towards the rear of the hospital in combination with associated developments and extensions at the Institute of Medical and Veterinary Science resulted in many of the old temporary sheds, buildings and maintenance areas of the hospital being replaced by modern buildings of pleasing design.

Not all of the buildings were new. Some renovations took place in the older nurses’ quarters which were redesigned for medical staff accommodation and a major renovation took place when the old outpatient building on the corner of Frome Road and North Terrace was redesigned as the Nurse Training Centre. Unfortunately the various buildings along the North Terrace frontage of the hospital still remain standing pending the final design and provision of funds for a new South Wing. These buildings remain in use for various displaced services or for services which were designed to be ultimately rehoused as part of a building across the front of the hospital incorporating a major entrance. The southern facade of the hospital still awaits its final resolution. The basic cake has been made but the final icing has yet to be applied.

Apart from the major structural changes which took place in this exciting decade there were equally exciting changes during this time in the medical, nursing, paramedical, administrative and domestic areas of the hospital.

On the medical side, the long-established tradition of the honorary system finally gave way to a system of sessional payments for visiting medical staff. Full time directorates were also established in areas such as thoracic surgery, neurosurgery, gastroenterology, endocrinology and renal medicine. New specialised units for intensive care and coronary care were developed and a dedicated burns unit was designed and appropriately staffed.

Domiciliary care and rehabilitation services were developed at Northfield Wards and a start was made on the redesigning of buildings at Northfield to provide new accommodation for patients inadequately housed in [those of] the old infectious disease wards [Metropolitan Infectious Diseases Hospital]. A number of technological advancements took place on the North Terrace site ranging from linear accelerators and CT scanners to laser technology and microsurgery with the aid of operating microscopes. Nuclear medicine came into being and formed an integral part of the hospital’s services although administratively part of the Institute of Medical and Veterinary Science. The advanced technological developments in pathology which occurred in the Institute of Medical and Veterinary Science form a story in their own right.

From the nursing viewpoint the 1965-77 period was also a heady time. The reduction of nursing hours to 40 hours per week resulted in endless discussions on roster arrangements. Increased annual leave brought its joys but also its problems in arranging for continuity of staff. The development of study day and block training programmes occupied endless hours of debate. The final abolition of broken shifts and the closure of Magill Wards ensured that nursing staff members functioned more cohesively and were less subject to ad hoc deployment demands. Nursing progressively moved from a situation where the nurses’ reward was paid by heavenly recognition to more tangible financial rewards in the present world. A major change in professional emphasis took place when patient orientated nursing gained precedence over task orientated nursing. Refresher courses for married nurses wishing to return to their initial vocation were strengthened during this time and post-basic courses in the areas of coronary care and intensive care proved attractive to many nurses with an interest in developing advanced clinical and technological skills.

From the paramedical viewpoint developments were less dramatic but still significant. There were increases in the social work staff, physiotherapy staff and occupational therapy staff. A more sophisticated use of these services took place. Radiography training was enhanced and a clinical teaching unit for trainee radiographers was established in the hospital itself. A dramatic upsurge in numbers training in medical technology also occurred during this period of time in the hospital’s partner in pathology – the Institute of Medical and Veterinary Science.

It was the administrative component of the hospital that changed least during this decade. The old triumviral board which had been in existence since 1922 continued throughout the 1967-77 period. The chairman remained the director general of medical services and Shea and Dibden followed in direct descent from Morris, Jeffries and Rollison as the appointed chairmen of the board. There were also few changes in the other two board members, Mrs Williams having earlier succeeded Miss Carroll and Mr Cole later succeeding Mr Dawes. This decade was also the Rankin/Hooper period in the office of administrator, the Kennedy/Spry period in the office of matron and superintendent of nurses, later retitled director of nursing, and Nicholson/Kearney in the position of medical superintendent.

The introduction of Medibank cost-sharing was weathered during this decade without major disruptions occurring. One side benefit of the scheme was that patient assessments for fee payments were no longer required. Warrants for nonpayment of fees leading to possible imprisonment became memories of the past.

There was still, however, during this period of time, a reluctance in public service quarters to agree on adequate salary levels to attract second level administrative staff with demonstrated financial and managerial skills. An increasing number of younger officers were recruited into health service administration but training in this area still remained very much along traditional apprenticeship lines. Some progress was made, however, and I can still recall the intense interest of the hospital when its first personnel officer was appointed. Nowadays the development and staffing of comprehensive financial, managerial and personnel sections are taken for granted.

The domestic side of the hospital was appreciably enhanced during this decade. There were major increases in cleaning staff partly as a result of vast increases in floor and corridor areas resulting from the much larger sizes of the new buildings and partly because the nursing staff were no longer required to act as glorified domestics and cleaners. When one recalls the old days when ward areas were literally covered by a sea of black beds, cleaning, bed making and care of the patient were inevitably closely intertwined. Cleaning of the floors in those days was often a matter of cleaning under the patient himself.

In the decade under review, catering services were also supplemented by the employment of non nursing staff and floor pantries were designed to service groups of wards rather than single wards only. The introduction of frozen food came later in the piece after initial experiments at Glenside and Modbury Hospitals and received a very mixed reception. For obvious reasons I would prefer not to pursue this matter in greater detail.

In outlining some of the developments which spring readily to mind during the 1967-77 decade, my major image is still the memory of a very large number of staff members at the Royal Adelaide Hospital united in the common purpose of providing better patient care. With this in mind I can do little better than to quote again Estcourt Hughes in his epilogue section in the published history of the Royal Adelaide Hospital. In late 1966 Estcourt Hughes expressed the following sentiments

The writer hopes that in the preceding pages he has demonstrated adequately that, both as a place of healing and a place of instruction, the Royal Adelaide Hospital deserves to be described as a great hospital. That it will have the fullest opportunity to continue in this role there can be no doubt. The question is how the Hospital will make use of this opportunity. In his Hudson and Deck Memorial Lecture delivered in Sydney in 1965, Professor C R B Blackburn quoted an American writer as saying ‘the functions of a teaching hospital are first to advance knowledge, second to set an example in practice and third to train future doctors; they are not primarily to cater for local needs”. Whether this is a valid proposition or a mere academic pipe dream does not matter because it is impossible to imagine that in the foreseeable future there is any prospect of the Royal Adelaide Hospital being divorced from local needs. It is also difficult to believe that the other elements of this concept will rank in the order given, certainly not until the teaching hospitals in Adelaide are able to train enough medical graduates for the needs of South Australia. …

It has been suggested that an attempt should be made to establish in Adelaide a medical centre where clinical, teaching and investigational facilities would be concentrated. At present all these services are available within or adjacent to the Royal Adelaide Hospital but there is no unified authority to co-ordinate the activities of the various elements. …

The University controls the Medical School, the Institute of Medical and Veterinary Science has its own Council while the Board of Management is in charge of the Royal Adelaide Hospital including the Dental Hospital. Many obstacles would have to be overcome before a single controlling body could take over from these existing authorities. While this appears to be a reasonable ideal, it is impossible for the writer of this book at least, to agree that the Royal Adelaide Hospital should become merely a part of the Medical Centre. What should happen is that the Hospital should become the Medical Centre and that in doing so there should be no change of name. The sponsors of this plan for a medical centre are quoted as saying: “The old buildings of the Royal Adelaide Hospital seem to perpetuate the ‘Poor Law’ attitude to public medicine. This image tends to reduce public confidence in its services. With the Hospital rebuilding programme well advanced, now is the time for a new look and a new name to destroy the old image completely.” What utter nonsense! To have made this statement means that all those responsible for it have failed completely to appreciate the changed public attitude to the Royal Adelaide Hospital in recent years. It cannot be denied that at one time the Hospital was regarded with a certain amount of fear and suspicion. Those days have gone and the public now realizes that the Royal Adelaide Hospital provides services which are not obtainable anywhere else in South Australia, or, for that matter, in Australia. The changed attitude is also shown by the readiness with which people now accept the advice that they should go to the Royal Adelaide Hospital either as inpatients or outpatients.

These words are still as fresh and as pertinent today as when written by Estcourt Hughes. He was also prophetic in other comments in the epilogue and it is fascinating to recall further some of his other words today in the light of the pressures for tighter financial control in hospitals which is so common-place in Australia at the present time. Again in 1966 Estcourt Hughes wrote

One problem which the Royal Adelaide Hospital will face along with all similar institutions, is that of the steadily rising cost of maintaining them, which threatens to become prohibitive. In some quarters it is felt that compulsory medical insurance should be introduced to help solve the problem, while others hope for a rich harvest from lotteries sponsored by the government.

The issues mentioned are only a few of those which will doubtless arise for the Government, the administration of the Hospital and the Honorary Staff. Above all tolerance between the various parties concerned will be necessary and some individual sacrifices will have to be made for the common good. Those whose thinking is conservative must yield a little, while the radical element must be prepared to take things quietly. After all a motor car needs both a brake and an accelerator!

The challenges to the present Board of the Hospital – now fortunately much enlarged and representative of the community interests – and to the present staff of the hospital are still great and many. The standards of patient care, the quality of teaching and the promotion of research in this outstanding hospital must continue unabated. To continue these activities in a tight financial situation represents an exercise in ingenuity and skill. All staff members at the Royal Adelaide Hospital have a long tradition of meeting crises successfully. I have no doubt that this will happen still in both the clinical and administrative areas.

I also have no doubt that in the longer run this great hospital will be successful in completing its fourth stage of building development. I have visions of a vastly improved front entrance and associated services. Throughout its long history there has been no time for the hospital to stand still. The care of patients has constantly continued throughout all rebuilding and staff development phases. Attention to admissions has been constant and the quality of patient care has never wavered. Like the Windmill Theatre in London the Hospital has never closed its doors to the community.

The hospital is constantly changing and yet remains unchanged in the sense that the essential dedication of this institution to the principles of alleviation of suffering and restoration to health where possible, has been constant through its history. Royal Adelaide Hospital today is a reflection of its past history, its honour and also the humility of its staff. We should all be proud to be associated with it.