Methods of appointment of honorary medical staff had changed little for over 40 years. Appointments were made by the Hospital Board every two years, and there was no certainty of reappointment. During the 1920s, both the Board and the medical staff expressed a wish to improve both the method of appointments, and also to have more security of tenure for those appointed. Discussions were extended to the question of the structure of the honorary medical staff. A new category of appointment was created, that of Honorary Assistant Physician or Surgeon. The concept here was that these posts would be available to younger and less experienced graduates for the purpose of gaining hospital experience, and at the same time providing assistance to the Honorary Senior Physicians and Surgeons. Additionally, there was the expectation that when senior positions became available, they would be filled from within the assistant ranks.
Dr D Macdonald Wilson, Medical Superintendent returned from extended study leave in the USA and Canada in 1923. In his report to the Board, in respect of medical staffing he wrote:
"I would recommend that the honorary staff be reorganised early next year, and that there be appointed surgeons and physicians with assistant surgeons and physicians: the assistants to relieve and assist the seniors in ward work, and also to control the out-patient department. Future senior appointments should be made from the assistants. Continuity of service is to the advantage of the hospital, and a system of election whereby members of the honorary staff can depend upon appointment for a reasonable period should be instituted."
The assistant staff did not have any beds of their own, and were required to seek the permission of their senior colleague before admitting one of their own patients. The first assistant surgeons and physicians were appointed in 1924. Thus there was a significant increase in honorary medical staff, and this system of the pairing of seniors with assistants continued until the 1960s. Honorary senior medical staff were required to retire after 20 years service or upon reaching the age of 60yrs. An interesting regulation was in force for some years, namely that, 'if two or more medical practitioners are in partnership (ie private practice), only one shall be eligible for election to the honorary staff'.
The Board retained the sole right to make all appointments, but agreed to the concept of having one or more advisors involved in the selection process. By 1932, a Medical Appointments Committee had been established, comprising the Chairman of the Board, another Board member, the Medical Superintendent, the Pathologist, and representatives of the Colleges of Surgeons and Physicians. Any recommendations made by this committee were subject to approval by the full Board.
The honorary system of medical staffing had served the hospital well since it was first introduced in 1879. The hospital benefited from the experience of these practitioners at no cost, and the honorary staff benefited from access to hospital beds and facilities for their patients, and to other patients with a wide range of medical and surgical conditions.
The honorary staff generally attended the hospital in the mornings, and attended to their private practices in the afternoons and evenings. As the hospital progressively expanded, more and more of the City's population took advantage of the increasing range and standard of services available. This was particularly the case in the Out-patient Department. Dr John Ewart was intially responsible for the popularity of the service, and this continued after his retirement. Although charges to patients for hospital services - both in-patient and out-patient - were in operation prior to 1940, there were many defaulters. Additionally, some patients who did pay may have been happy to do so at a rate lower than that operating in private practice.
The 1929 - 1934 Depression saw a marked increase in the number of Wellington's unemployed, and this in turn placed a strain on the hospital's facilities and its welfare budget. In an attempt to stem the tide of patients attending the hospital, a means test was instituted in the Out-patient Department, but this proved to be contentious and by 1934 had been abandoned. This led to the following 1935 report to the Board from the hospital medical staff:
"It is the opinion of the combined staff, both honorary and stipendiary of the hospital, that a system of a hospital open to all members of the community, both as out-patients and in-patients, is incompatible with honorary service on the part of medical staff. Honorary service is traditionally designed for the treatment of the indigent sick."
The Board received the report, and a slow move toward the abolition of the honorary system began.
By 1938, the Board Chairman reported that "The time of honorary service is past". The Board proposed that the medical staff be reorganised, and a major part of this proposal was to increase the numbers of full-time staff. Wellington's practitioners, through the local branch of the BMA, protested and a number of meetings were held between 1939 and 1941 before the staff structure was finalised.