and a few of the other large cities which supported provincial medical schools. A second great achievement was the catalyst which the Health Service provided, by virtue of its management and financing, for the rapid evolution of several specialities. Both of these notable achievements have been well described by Sir George Godber. "The evolution of many of the specialities has taken place largely during this century. In addition to the physicians and surgeons there were gynecologists and obstetricians, pediatricians, opthalmologists, otologists, and pathologists in main centers at the beginning of this century. But over most of Britain, these specialties were only slowly being separated between the wars, and differentiation was not complete when the Health Service was introduced in 1948. The one immediate effect upon medical practice after the change in 1948 was to complete, in a matter of two years throughout the country, not only the separation between specialists and generalists, but also the differentiation of the specialities. There had been many general surgeons who undertook surgery or gynecology or even otology; there had been specialists in internal medicine who were also pediatricians or perhaps pathologists or even radiologists. The reason for this was simply financial, because hospital work had been unpaid, and private practice outside of hospital or in a few special beds in hospital was the only support of specialists. Hospital patients, who were the majority, did not pay fees themselves. Once work in hospital became remunerative, appropriate staff could be appointed in the numbers required, so far as suitably trained people were available. At the same time, the division between specialist and generalist was completed because very few generalists remained with hospital appointments in specialties; most of those who were fully trained in a specialty turned to the specialist side of their practice. . "The first ten years of the hospital service were substantially devoted to organizing and developing clinical services within each mixed group of hospitals, and to providing a rapid expansion of staff in the specialties. Despite lack of resources for building, and the gross inadequacies of much of the accommodation that existed, a reorganization of function within each group and great improvement of quality of work was possible. Moreover, these changes could be brought about without the standard dependence on local resources, since the cost was met by the state. Where the need was greatest, most could be done and what building was possible could be undertaken where the need-rather than local wealth-was the most manifest." New Hospital Construction The evolution of specialization and its more equitable distribution in the early years of the Health Service were achieved principally by creating and paying for the appropriate staff appointments and providing these specialists with refurbished facilities. During the first ten years of the NHS, there was virtually no major capital investment in new hospital construction. The physical plant of the hospital service took on more and more the appearances of a patchwork quilt as the armamentarium of modern hospital medicine was crowded into buildings designed for service in a simpler age. The need for long-term planning became obvious and in 1962, the Ministry of Health presented an ambitious scheme, "A Hospital Plan for England and Wales". (Ref: Command 1604, H.M.S.O.) This was 71-413 O 73-4 much more than a plan for new hospital construction. It included comprehensive plans for the functional integration of services and for accommodating and responding to the exigencies of change. The plan was built round the concept of the "District General Hos pital", in which the full range of in-patient and out-patient diagnostic and treatment facilities would be aggregated. In addition to the traditional specialty services, the district general hospital was planned to include a geriatric unit, obstetric services, and a short stay psychiatric unit. Such hospitals were designed to encompass 600-800 beds and would serve a population of 100,000 to 150,000. By the late 1960's the plan was modified to increase the size of such hospitals to 1,000 to 1,500 beds serving a population of 200,000 to 300,000. More emphasis was placed on psychiatric and geriatric treatment and, of even greater consequence, the hospital was to be better integrated with surrounding community health services. In the modified plan, general practitioners and "general practitioner beds" were to be included in the new district general hospitals. By American standards the progress of implementing these ambi tious plans has indeed been slow. As the first stages of the plan were implemented, the operating costs of existing hospitals were escalating, capital for new construction was less abundant than originally planned and the first new district general hospitals proved much more expensive than even the most liberal estimates had suggested. This led to a re-appraisal of the concept, a more penetrating analysis of the pattern of utilization of hospital beds, and a careful examina tion of the economies that could be effected by better integration of hospital services with the surrounding ambulatory health care resources of the community. As a result of such analyses, the concept of the "Best Buy" hospital emerged (see "The Way Ahead," appendix VII). The first two such hospitals are now under construction, both near London. Both involve the same general architectural design, one which allows flexible use of the space allotted to patient accommodation and effective integration of the support services. While construction proceeds, great care is being taken to mold the staff who will man the new facilities into an integrated team which is being extended to include the general practitioners from the surrounding areas and others responsible for ambulatory health care and social services. All are being given management training and every effort will be exerted to decrease expense by increasing patient throughput. All concerned are now aware that this requires tight integration between the staff and surrounding services. A great measure of success has already been achieved in that the length of stay in the older hospitals in which these staffs are now working has dropped over the past several months from 13.5 days to 8.7 days. Further analysis by Americans of these imaginative experiments in hospital construction and management should prove rewarding. Geriatric, Convalescent and Psychiatric Care and Care for the Chronically Ill In Britain, as in the United States, these services seem to attract less imaginative attention and substantially less financial support than the more glamorous activities surrounding the diagnosis and treatment of acute organic disease. The British are dissatisfied with their present level of achievement. Yet honest comparison with comparable services in the United States would make the British justifiably proud of what they have accomplished. These services best exemplify the need for unification in the NHS as the requirements of these groups of patients fall within the ambit of all three branches of the service to a greater extent than do any other groups in need of health care. The extent and effectiveness of integrated effort by relevant parts of the tripartite system at the local level is already impressive. Here, too, the egalitarian principle of health care delivery in the United Kingdom is shown to best advantage. Here, too, can be found countless examples of effective partnership between government spending and voluntary private effort. Their success is certainly not uniform. Indeed, in the late 1960's there was a series of public scandals involving alleged mistreatment and neglect of patients in a few of the hospitals for the mentally handicapped and elderly. The national debate which followed these allegations led eventually to the formation of a Hospital Advisory Service, an independent body which was charged with analyzing conditions in hospitals in the NHS, particularly those for the mentally handicapped, mentally ill, and the elderly. The first annual report of the Hospital Advisory Service is appended (Appendix VIII). Σ CHAPTER IV The Private Sector In 1969 the Labour government commissioned a private consulting firm, Political and Economic Planning, to undertake an independent, non-party enquiry into the private sector of medical care in the United Kingdom. The enquiry was stimulated by a period of national debate over the growth of private practice in recent years, particularly the growth of non-profit insurance for private care. This is a source of concern to some who feel that the egalitarian principles underlying the NHS are threatened by significant growth in the private sector of medical practice. They feel that private medical care diverts valuable talent and energy from meeting the heavy commitment by government to provide care within the NHS. The key advantage to the private patient, the selection of a convenient time for admission to hospital for treatment of non-urgent problems, is viewed by those opposed to private medicine as basically iniquitous "queue jumping". Some of the opposite persuasion encourage growth in the private sector because they feel that the dominance of public spending has curbed the total demand for health care and that growth in the free market element represents growth in the total spending for health services. They point to the 600 beds for private patient care constructed by the Nuffield Nursing Homes Trust (sponsored by the British United Provident Association which has almost 80% of the non-profit insurance market) as net additions to hospital services. They recognize the ability of the private sector to respond rapidly to technologic change and point to automated screening and cervical cytologic testing as examples of this pace-setting function which the private sector provides to stimulate change and innovation. If such innovations prove to be good, the NHS is spurred by example to supply them on a national scale. If they fail the test of time, public expense is spared. The PEP Report (see Appendix IX) was prepared by Michael Lee by May 1970. A few weeks later there was a change of Government. There followed a period of indecision as to whether or not to publish the report, but it was finally made public in mid 1971. His report has received wide acceptance for its impartiality and its balanced view. The report estimates that the total amount spent for private patient. care represents just over 1% of the total NHS expenditure. It points out that this expenditure is concentrated in the hospital sector of the NHS, i.e. for specialist services. (Private payment for primary care provision, i.e. general practitioner services, has never been of any consequence whatever since the inception of the NHS. The vast majority of patients, including upper middle income and even upper income groups seek primary care within the NHS.) As private exepnditure is concentrated in the area of specialist services, here the amount paid to specialists, the report estimates, may |