The Subcommittee learned a great deal of value from the British experience in new hospital construction. This is embodied in their concept of the district general hospital.

At the inception of the Health Service, government took over most of the existing hospital physical plant. By and large, this was antiquated and dilapidated, rather similar to some of the older municipal hospitals which are found in many cities in the United States.

In the early years of the NHS, the chronic underfinancing was particularly manifest in what amounted to virtually a moratorium on new hospital construction. The grossly inadequate sums allocated to capital expenditure were spent largely in patching and extending the already outmoded existing hospitals. However, criticism of this flagrant under-funding must be tempered by the realization that it was the considered expression of central government policy of the day Specifically, successive governments, probably wisely, placed education as a recipient of scarce capital funds in higher priority than health. This moratorium on new hospital construction was not without its advantages. When government finally turned its attention to this matter in the 1960's, a great deal of thought was given to the planning of new hospitals. In the interim, a quiet revolution had occurred in the complexity of the modern acute general hospital. In developing the structural and functional concepts of the district general hospital, the British were able carefully to analyze the trends in this development. What has emerged would excite the envy of those concerned with rational planning of new hospital construction in the United States.

The Subcommittee was enormously impressed with how much has been done, with comparatively meager resources, to improve the quality of life for the elderly and those suffering from chronic illness. While the British seem dissatisfied with their present level of achievement, the standard of care provided for these patients and the imaginative innovations in their management stand in striking contrast to the common neglect and nihilism which growing numbers of elderly and chronic sick face in the United States. The Subcommittee obtained impressive firsthand evidence of the enormous benefit which can accrue to this disadvantaged segment of the population from the effort of intelligently interested professionals, who work together as a team, to improve the quality of care and the quality of life for both the patients and their families.

In striking contrast to the United States, where there is an enormous gap between the acute general hospital and the custodial dumping ground of the public nursing home and its expensive private counterpart, (which may be a bit more comfortable and less unattractive, but which is not much less depressing nor significantly more successful in achieving rehabilitation), in Britian the Subcommittee saw the egalitarian principle underlying the National Health Service at its best. At impressively low cost, they have implemented dynamic programs for care and rehabilitation for the elderly. The central objective is to maintain them as functioning members of society as long as possible in their homes rather than to incarcerate them in depressing custodial institutions.

This is achieved by accurate initial assessment and frequent periodic professional review of their status and potential in pleasant, cheerful,

ing care is applied in these units in conjunction with vigorous efforts in rehabilitation and training in self-help. This leads to early discharge. but contact is not lost. The patients are not thrown out to fend for themselves or to burden unduly the resources and patience of their families. Periodic review is maintained on an out-patient basis and an impressive array of home services is provided. These include home nursing services, mental health services, visiting pysiotherapists and occupational therapists, home help services, meals-on-wheels and a variety of other aids to maintain the patient as independent as possible for as long as possible in the home environment.

The more impressive of these programs clearly demonstrate effective collaboration among the three branches of the NHS at the local level. In addition, the team effort includes a heavy commitment from voluntary agencies. The latter include a wide range of activities such as "friendly visiting", social clubs, workshops, group holidays, day care organized by "good neighbor" groups, service from youth clubs and schools, assistance from non-profit building societies and Red Cross loan schemes. It has frequently been claimed that provision of comprehensive health services organized and financed by government effec tively kills voluntary effort and private initiative. Perhaps it can. In this sector of the NHS, however, the Subcommittee found impressive evidence of the vitality and value of service by a broad spectrum of voluntary agencies working in close and effective cooperation with government.

The remaining lessons from the British experience are largely negative.

(1) There is a deficiency of competent management of health resources. As in the United States, doctors have been dispro portionately influential in directing expenditure of public funds and generally have been totally untrained to be sensitive to the costs and other social consequences of their clinical decisions. Only comparatively recently has attention been given to appro priate training for managers of health resources but the number of such competent managers is still inadequate

(2) The system is unnecessarily rigid and does not make suffi cient allowance for experimentation and regional variation.

(3) Financial control is archaic in form, remote and heavyhanded. Many of the key decisions are made by civil servants the Treasury who are far removed from the practical problems which confront those more immediately responsible for health care provision.

(4) The rigidity and lack of dynamism in the system serves frequently to depress morale, to reduce efficiency, and to discour age constructive and imaginative responses to meet the demands of the growing pace of change. Nowhere is this better exemplified than in the recent history of the management of medical man

(5) Insufficient attention is given to health services research. Both the quality and quantity of such research is inadequate and appropriate feedback is lacking from the results of such research to those responsible for policy and planning.

(6) There is insufficient attention to development of meaningful and useful measures of quality of care in Britain. "An apparently widely held attitude is that quality of physician care is somehow an inappropriate subject for research. Even though operational research is used to obtain some information on the effectiveness of services, this does not extend to analyzing the effectiveness of professional services."

(7) British hospitals like those in the United States, are heavily dependent on medical graduates from developing countries for essential medical services. Almost 50% of junior hospital doctors (interns and residents) come from abroad. They come to train, are usually given the less attractive training posts and are really admitted in such large numbers because of the dire need for their

services.

The Subcommittee must hasten to point out that all of these deficiencies are widely recognized by those responsible for health care management in Britain. However, in their particular system, change is inevitably slow. To an American interested in reform of a chaotic delivery system at home, the important lesson to be learned here is the need to avoid, in the process of reform, repeating these costly errors. In summary, the Subcommittee received overwhelming evidence to demonstrate the value of government commitment to provide health care of high quality to all its citizens. The NHS is certainly not perfect, but it has effectively achieved a large measure of social justice in an area where the United States, for all its wealth and power, has failed so far to recognize good health care as a matter of right. The British provide this service at substantially less cost per capita than we do and they enjoy the cooperative support of the doctors, dentists, nurses, and countless other health professionals who serve in the front lines of health care delivery.

The NHS stands as an impressive jewel in the crown of national pride. We should accept its underlying philosophy and give effect to this commitment in a form appropriate to our own national history and our present needs and resources. The whole system deserves our careful study. Much of it we should emulate.

CHAPTER III

The National Health Service

HISTORY

The National Health Service came into effect on the 5th of July, 1948, and was based on legislation enacted in 1946 (for England and Wales) and in 1947 (for Scotland). It was much less revolutionary than is widely believed in that it perpetuated, even accentuated, the pre-existing divisions in health services. These principal divisions were: 1) hospitals, 2) general practice, and 3) the public health services. Each of these separate elements were well established prior to the inception of the National Health Service. A definitive history of development of each would be inappropriate in the context of this report, but a brief sketch of their respective paths of evolution prior to 1948 will serve, particularly regarding the first two divisions, to illustrate two principles which have broad international application.

Firstly, when governments extend their involvement in the financing and administration of health care delivery, they must build on present patterns of organization and administration. The process is more evolutionary than revolutionary. Even when such changes are, as they were in the United Kingdom, of the order of major reforms, what emerges inevitably reflects to a great extent the pattern of organization of health resources which exists before such reforms are effected.

Secondly, major evolutionary reform seems only possible when systems are on the verge of collapse, when circumstances have deteriorated to the point that consensus can be forged for effective political action, action which is more consequential than minor amendment and patching. In the British context fairly comprehensive proposals were submitted to Parliament as early as 1920, (Command 693, 1920), but no effective action was taken until after the Second World War when the hospital service, particularly, was on its knees.

(1) Hospitals

Hospitals first made their appearance in an era when effective therapy was virtually non-existent. They were established, principally by religious orders, as charitable institutions in which supportive care could be provided for the sick poor. Somewhat later they were founded as well by groups of public spirited philanthropists and, in the public sector, by local government.

As they involved the gathering together in one place of numbers of sick people, they provided the institutional focus in which most of the critical advances in clinical medicine were made. For much the same reason they became the principal institutions in which medicine was taught.

With the gradual emergence of modern scientific medicine in the latter half of the nineteenth century and with the rapidly accelerating

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