can doubt the stimulus that this brings to the doctors concerned. The great majority of such hospitals are in smaller communities; our challenge is how to create similar privileges in the main urban areas.

There is a forceful argument for bringing the general practitioner into the hospital in the interests of the hospital itself. There is an almost inevitable tendency for hospitals to become self-preoccupied. Their links with the community and contacts with the outside world are in some respect tenuous and limited. What is most dangerous about this is that the hospital staffs themselves are often unaware of their restricted vision. The general practitioner is the natural link because he is in fact the exponent of clinical care in the community. If we reversed our policy and brought general practitioners back into the hospital, for a time the hospital would be giving most, as it reinforced the practitioners to hospital methods and standards, but after a while and as a new generation arose, the hospitals would gain from the arrangement at least as much as the general practitioners. Perhaps it will after all be necessity, the most compelling and simplest reason of all, which will bring the general practitioner the return of his birth-right. I suggest that it is a fairly simple exercise in logistics to see that, unless we assume a permanent subvention of medical assistance from overseas, many hospitals outside the teaching centres will only get a satisfactory level and continuity of staffing by working out a new deal for the general practitioners.

The desirable policy of hospital association and the necessity for a new set-up and organisation for general practice, fit together to suggest a potent new alignment for our medical care arrangements. One can envisage the district hospital at the centre of a constellation of health centres, with perhaps a central one in its own grounds, with a two-way traffic of staff between hospital and health centres; with all of the general practitioners having some functional association with the hospital either continuously or on some split time basis, and with hospital staff involved in the work of the health centres.

Change and the National Health Service

Public health

For almost a century up until 1948 the local authority with the medical officer of health was the main vehicle of public medical organisation. Since 1948 the local health authority has tended to be overshadowed. The main effect of the National Health Service Acts upon local authorities was to take away their responsibility for clinical services while at the same time extending their responsibility for certain auxiliary domiciliary services. At the time it was said that this would enable local authorities to concentrate more effectively upon their main work of prevention. Whatever the logic of this view may have been, general impression suggests that the change was a serious blow to the morale of local authority services. There is nothing historically inevitable about this administrative separation of public health from clinical services. In fact at various points in our recent history the trend was towards unification. It was the administrative setting of public health services and professional distaste for this which determined the divisions in 1948.

Faltering morale and sense of direction are not peculiar to our own public health services; they are in part symptomatic of changes which have affected all countries with highly developed medical services. As medical technology has become more effective and as specific acute infections come under control, the trend is for the new problems of preventive medicine to become more closely associated with clinical medicine. The personal health promotive services of maternity, childhood and adolescence take on a new challenge as the grosser forms of deviation from health become rare. They require an alliance of the best clinical skills with the assessment and educational techniques of

public health. Primary prevention is to a great extent a matter of achieving behavioural changes which are most likely to be accom

plished with the assistance of a direct personal relationship such as the general practitioner can have with his patients. Presymptomatic diagnosis involves the use of hospital laboratory resources, and the close collaboration of general practitioners to obtain access to the population at risk. Problems of secondary prevention-i.e. preventing or reducing the

Brotherston

disabling effects of disease once incurred are increasingly important in an era when degenerative diseases are the most serious morbidity problems and involve the closest possible links with clinical and rehabilitation services.

Yet the clinical relationship which the medical officer of health had with the doctors of his area through the hospital and other clinical services has been attentuated. No longer must he be looked to in the same way for the kinds of help most familiar to the practitioner. This has tended to identify him as a purveyor of auxiliary assistance rather than a member of the clinical team. The responsibility for prevention is still almost uniquely identified with the medical officer of health. This has the consequence that doctors in the clinical services tend to think of prevention as someone else's job; and at a time when increasingly it can be seen that prevention can only be accomplished by the united efforts of all arms of the service, we are in a position where the responsibility for prevention appears to be in specialist hands. Yet at the same time the specialist is in some measure cut off from the resources necessary for him to do his job.

The medical officer of health still has his traditional responsibility for supervising and maintaining the health of his community. Yet there is no official means for him to assimilate and summarise as a whole the operational statistics of the health services of his area. Nevertheless, it would seem essential that somewhere in each major community there should be clearly established the responsibility and means to assess and report on the manifold activities of the health services. If the medical officer of health is intended to be such a person then this should be made easy for him.

Three points should be noted. First the prevention and curative medicine are more and more closely linked: so much so that at a personal level they become virtually indistinguishable. It is quite certain that without the closest support from general practitioners and hospital services most preventive policies other than purely environmental will now be less than effective. Secondly, for all kinds of problems clinical as well as preventive, the

community and epidemiological approach traditional to public health and the medical officer of health becomes the relevant approach for medicine as a whole. It is the epidemiological approach which will identify the most vulnerable groups; for example, the low social class and high parity mother who is a special risk both in respect of perinatal death for her babies, and cervical cancer for herself. She is the woman least likely to seek appropriate help in time. She can only be dealt with effectively if the machinery exists to identify her and seek her out. Here technology is coming to the assistance of population medicine. The application of the computer as a memory system and prompter in population control of health and disease opens up entirely new possibilities for taking medical initiatives on a population wide basis (Galloway, 1963).

The third and most important point is to note the serious impairment to the potential of all our health services at the community level created by the absence of an effective strategy and direction of all resources towards the major objective of improvement of community health. So important is that objective, so significant is that missing element that we must create a new alignment of our community forces to bring them into an integrated and co-ordinated pattern.

The National Health Service

I have discussed some of the effects of social and scientific change on health problems and institutions. Perhaps the main question in relation to the National Health Service, if one could answer it, would be; how far has the National Health Service promoted or held back the good and ill effects of these changes? There is no doubt it has vastly increased our capacity to make available in all parts of the country the costly resources of a modern medical care system. Unevenness of spread, duplication of service in favoured areas and under-provision in others was the message of the pre-National Health Service Hospital Surveys. It is still a commonplace in many other countries. Nevertheless the service has curtailed by its organisation some important possibilities for development and experiment. The precise terms in which it laid

down the responsibilities of a tripartite administration has made it difficult to experiment with new alignments of responsibility between hospital and community health services. There has been a great deal of exhortation to co-ordinate planning and resources between the different parts of the service and many valiant efforts to do so, but the fact is that separate administration and separate budgets make it very difficult to go beyond a measure of parallelism in planning, into new forms of experimental service which should include elements of hospital and community health care under one plan. And yet it is just such developments which are needed to explore and exploit fully the capacity of scientific medicine in a community health service. Until we have the full capacity to co-ordinate and deploy all health services to the united purpose of health improvement, we shall fall short of the full attainment of potential from our effort.

Another comment to make on the balance sheet is that the services have little more capacity for moving over to the initiative than in 1948. It is still only the traditional services of maternity and child welfare and school health which make any systematic attempt to discover undiagnosed disease and disability The curative services of general practitioner and hospital still operate on the traditional 'on demand' basis. It is the patient who presses the button to make the service work. But the first tentative steps are being taken to change this. Much has still to be learnt about the problems involved but the day will come when we will wish to swing into action in the detection of presymptomatic disease. And then we would find our tripartite organisation, if left unchanged, a severe handicap to our intentions.

How about our capacity to use the national organisation of the service to sort out and put into effect, nation-wide, the right priorities at the right time? The organisation has been largely concerned until recently with getting the service into being and with ensuring during a period of mounting costs and limited finance, a reasonable return for money spent. It inherited no research organisation to guide it: nor was there previously a body of expertise on how such a service might best be

Change and the National Health Service

guided to improve understanding and e-f ficiency. But recently there has been a significant change, both in respect of the interest in analysis and the development of methods. Studies have been made on specific services and components of services, and solid groundwork has been laid in the collection of data which can be used to examine ongoing work, and from which studies in comparative performance can be begun. We are still a long way short of full capacity to make operational and cost benefit studies to enable us to see more clearly the consequences of re-allocating resources between different services. But at least some of the targets have been defined and work has begun. Most important of all the need for this kind of approach has been clarified and accepted. The responsibility has been recognised. We should note the need, almost the most urgent of the many claims on resources, to increase the numbers of people who have the talent and skills for this kind of work. It is only as we begin to realise the need and opportunities for operational studies of the service that we appreciate the lamentable dearth of people fitted for the work. They scarcely exist because the need for them has not been recognised. Nor will they come into existence with sufficient speed, with sufficient ability or in adequate numbers unless we create the opportunities for training and for careers which will attract a sufficient share of the brightest and best, from medicine itself, from the other health professions, from statistics, the behavioural sciences and from economics.

The potential of the Health Service for further improvement is vast although the gains already have been considerable. The responsibility of realising this potential belongs to us all, and especially to the medical profession. At all costs it must not be seen as a responsibility limited to a faceless thing called "Them" on whom all short-comings can be blamed. All of us have the responsibility to examine and influence the effectiveness of the medical institutions in which we work. Exciting new possibilities are emerging of doing this in more scientific and effective ways. But this kind of experiment and investigation cannot happen without the

Brotherston

goodwill and understanding of the medical profession. All of us have a responsibility to help and assist this analysis and self-analysis because all will benefit from it. The medical profession is charged with special responsibilities for the health of the people. It has shown its capacity to adapt the discoveries of science to the needs of the sick. It is for us to take the lead in using the same scientific methods to evoke the maximum benefits from the united efforts of the health services.

It is now 21 years since the National Health Service was inaugurated, and longer still since the debates and discussions and compromises which led to its present structure. A generation is a long time in the history of an organisation designed to support anything so fast changing as modern medical practice and the science and technology on which it is based. It seems inherently unlikely that an organisation designed so long ago, for such a different world of practice, of health problems and social aspiration, was so perfectly contrived that it is appropriate to our needs today.

Now it is our turn, our responsibility to reshape the service to match the needs of our society and medical work for the next generation. As a profession we have a special responsibility to our successors. We must design a service which can provide the support to every practitioner, and not just a privileged minority, to enable him to give a full rendering of his skills and abilities to his patients. The Green Paper on administrative reorganisation of the Scottish Health Services (Scottish Home and Health Department, 1968) gives the challenge. It is up to us to prove our capacity to face and plan for the future.

REFERENCES

Abel-Smith, B., Gales, K. (1964). British doctors at home and abroad. Occasional papers on social administration No. 8. London: H.M. Stationery Office

Biörck, G. (1965). The next ten years in medicine; attempt at an analysis of factors determining medical and social development. Brit. med. J., 2, 7

Brotherston, J. H. F. (1958). Some factors affecting the use of G.P's. services. In Recent studies in epidemiology, edited by Pemberton J., Willard, H. Oxford: Blackwell

Cartwright, Ann. (1964). Human relations and hospital care. London: Routledge

Cartwright, Ann, Martin, F. M. (1958). Some popular beliefs concerning the causes of cancer. Brit. med. J. 2, 592

Dubos, R. (1959). Mirage of health: utopia, progress and biological change. London: Allen & Unwin

Engel, A. (1965). Health planning in a changing society. World hospitals, 1, 255

Evang, K. (1960). Health service, society and medicine. University of London Health Clark Lectures, 1958. London: University of London

Evang, K. (1964). Problems and progress in medical care. London: N.P.H.G.

Ferguson, T., MacPhail, A. N. (1954). Hospital and community. London: Oxford Press

Feldstein, M. S. (1964). Effects of differences in hos. pital bed scarcity on type of use. Brit. med. J., 2,561 Galloway, T. McL. (1963). Med. Offr., 109, 232 Locke, K. R. (1965). Medical education and community practice in Britain. Medical care, 3, 182 Logan, R. F. L. (1964). Studies in the spectrum of medical care. In Problems and progress in medical

care. London: N.P.H.G.

The Way Ahead

An Experiment in Hospital Building and Medical Care

AB Harrington MD and

H Goodman ARIBA

Department of Health and Social Security

Blair Harrington graduated from Aberdeen University in 1938. He proceeded to the MD in 1944 while serving in the RAMC where he specialized in neurology and the rehabilitation of head injury patients, He is now Principal Medical Officer in the Department of Health and Social Security concerned with medical aspects of hospital planning. Recently especially interested in Research and Development Projects. especially the integration of hospital with other medical services in the West Suffolk and Farnham Groups. Howard Goodman is an Assistant Chief Architect at the Department of Health and Social Security and is concerned with the Department's Research and Development Projects, including the new Greenwich District Hospital and the 'Best Buy' Hospitals. He joined the Health Service in 1949 and has been concerned with the design and building of several major projects both at home and abroad since that date.

Great interest has been aroused by the news that the Department is to build in Bury St Edmunds and Frimley (Surrey) two experimental hospitals, which will incorporate not only new developments to improve management, but also planning arrangements to make it easier for hospitals to function as key points working in close co-operation with all other parts of an integrated health service. It should be a matter for rejoicing that advanced planning methods which will get buildings of the type foreseen in this experiment finished in five years have emerged.

Such is the essence of this exercise. But why need it be considered exciting? The answer is that these schemes are the first examples in area planning designed to explore the effect of unified deployment of all medical, nursing and welfare resources in the community. This in itself should lead to a reduction in morbidity and the need for service (Godber 1967).

However, there were more mundane reasons for taking a fresh look at methods of hospital building. At present the construction of new hospitals is expensive and the work is often completed in phases spread over 8 to 10 years or longer, Great inconvenience is caused where there is redevelopment of an existing site and this has been more often than not accompanied by frustration and disappointment. Where backlash of this type is associated with a cost for building and engineering alone of £8 500 per bed, it is time to re-think.

Aim

The two experimental hospitals are being built to a common design, thus saving cost and planning time. Each is being planned on the premise that an integrated

2

system of medical care will be in existence by the time the hospital is erected. The effect of the training of hospital and general practitioner teams in management, together with the study of the work involved in the treatment of all kinds of patients has been to indicate that a good service can be provided with a ratio of two beds for acute admissions per thousand population instead of the often-quoted figure of three such beds per thousand population. New methods for supply and disposal services, centralization of treatment suites and a design which promotes the use of some space for several functions in the day has helped to reduce the cost per bed to a little over £5 500. Small wonder that the experiment is known as 'the best buy' hospital design!

Pattern of Medical Care

Effects on General Practitioner

Doctors are probably more interested in the development of new patterns of care which continue to be actively canvassed than they are in the necessary but prosaic search for a bargain hospital building. The new methods presuppose the need to bring the general practitioner team (consisting of attached nurses, health visitors and sometimes midwives and social workers) into a closer relationship with the hospital. Conversely, the same methods imply the need to bring the hospital service into closer touch with the various people who treat and care for the patient in the community. The relevant question today is the role of the hospital in general practice affecting as it does the welfare and management of every patient.

General practitioners at Health Centres and in group practice with access to hospital diagnostic departments can find time to take part in clinical work in hospital, attend courses in postgraduate education and become interested in aspects of preventive medicine. Their hours are thus spent rewardingly, secure in the knowledge that the fostering of a co-operative outlook among all branches of the health services confers a continuity of treatment for their patients which can only work for the good of both patients and doctors. Effects on Hospital

What then is the effect of this scheme on the work done at hospitals? As many patients as possible will be investigated and treated in the community by general practitioners with the help of nurses and health visitors, and hospitals should expect a bigger percentage of their patients to be outpatients. Patients requiring minor operations which cannot be undertaken at a health centre and investigations needing the use of hospital diagnostic facilities will not be retained in hospital overnight (Williams 1969). The increase in the number of this type of day patient treated at West Suffolk General Hospital March 1967 December 1968 is shown in Figure 1. Effects on Patient

How does the patient benefit from hospital 'day surgery? One of his fiercest and most valid complaints has always been that entry into hospital, even for minor surgery, can disrupt his economic situation and wreck holiday plans or social obligations at some date in the uncertain future. The new arrangement will reduce the time he spends waiting for a hospital bed, because a definite appointment for treatment will be fixed when he is first seen as an outpatient. This will give him the opportunity to make preparations for his ordeal to take place on a fixed date. After operation, he will return to his home and be nursed by people he knows. All of this should have a beneficial psychological effect. Hospitals