By Dr. MEYRICK EMRYS-ROBERTS
Now that the Government have at last embarked upon a massive hospital building programme it might seem churlish to question its merits. But one aspect of the Hospital Plan, published two years ago, has caused a crescendo of protests. This is the threatened extinction of General Practitioner Hospitals (the modern counterpart of the Victorian Cottage Hospitals).
The essence of the Ministry's plan is now well- known: the provision over the next ten years of a nation-wide series of District General Hospitals ranging in size from 300 to 800 beds, each covering a population of 100,000 to 200,000. With it goes the closure Callow better provision to be made for' is the atraumatic euphemism employed) of some 1,100 hospitals, 600 of them specialist hospitals dealing mainly with such subjects as gynaecology, orthopaedics or diseases of the eye, the remainder General Practitioner Hospitals. For the former, the proposed incor- poration into the body of the big hospital means simply a transference of location and is welcomed by the profession. For the latter, the implications are infinitely more widespread and there is a grave danger that the planners, in pursuit of paper perfection, may destroy something that is good and capable of far-reaching development.
The theory behind the plan is that only large- scale hospitals can adequately mobilise all the resources of modern medicine and specialist treatment. This concept is at best only based on a half-truth. More detailed research by the Ministry might have revealed that nearly half the patients treated at these big hospitals have no need of the complex facilities which they afford. We are faced with a plan concocted in great haste with virtually no field research and no consultation with official representatives of the medical profession. If it is implemented in its present form, the General Practitioner Hospitals will be abolished at the rate of one every ten days from now until 1975. (Has there been anything comparable since the dissolution of the monas- teries?) Rather than become emotional we should ask three precise questions. 'Are General Practitioner Hospitals an anachronism? Will they be compatible with twenty-first-century medicine? How significant is their role to the whole practice of medicine?' To answer these questions we must cast back a hundred years when the first of these hospitals (literally in a cottage) was created to cater for the sick poor in Cranleigh, Surrey. New foundations appeared every six weeks for the next eighty years. Their doors were later opened to all classes, and many built originally in relatively isolated areas became engulfed by urbanisation. A number of first-rate General Practitioner Hospitals with up to seventy beds now flourish within the bounds of Greater London. By 1940 the breed had become an im- mensely desirable part of general practice, greatly prized by the local residents whose money and energy it represented. These small hospitals be- longed, in every sense, to the people. But the movement, halted by the war, could never be resumed, and in 1948 administrative necessity made them part of the Hospital Service.
In one way this proved an excellent thing. Advances in scientific medicine had too often by- passed the 'Cottage' Hospitals whose develop- ment was hampered by lack of funds and poor communications. But the National Health Service brought X-ray, pathology and specialist services to an extent never possible before. And by a process of natural evolution the small hospitals have come to accept a restricted reper- toire, referring the more complex cases to the big. For example, all serious accidents are automati- cally taken to the big Group Hospitals. The majority of minor ones are treated by the GPs— with consultant advice where needed. In many areas, such as Walton-on-Thames and Weybridge, an advanced state of partnership has already been reached in which the one type of hospital is complementary to the other.
The key to the situation is the principle of selection. Patients, when they become hospital cases, do not suffer a sea-change: their needs vary according to the severity of their condition. Yet under the Ministry's plan there will be no selec- tion. All cases, major, minor and minimal, will be bundled off to the vast new medical emporia, swelling the already gigantic crowds in Out- patients, competing for blood-counts and X-rays, and cramming the wards in numbered anony- mity. Meantime the deprived general practitioner must inevitably come to contribute to the mystique of specialisation. With every case that passes from his care his experience will diminish; his confidence wilts as his experience dwindles; the more readily he passes on the next case to the specialist. Whereas, given the facilities and visiting consultants, the general practitioner can continue to treat a vast number of conditions such as pneumonia, bronchitis, and other infec- tions; a large proportion of heart disease and stroke illness; the old, infirm and the dying; a hard core of commonplace surgery such as that for hernia, piles and varicose veins; a large pro- portion of gynaecological operations; and, of course, a multitude of minor injuries, infections and suchlike in the Out-patient department.
The explosive rise in the cost of district hospital building and maintenance accentuates the need for simpler patient-care wherever applicable—an interesting paradox which hospital planners are coming to recognise. The delegation of work to satellite General Practi- tioner Hospitals fulfils this need. It also increases the attractions of general practice, providing centres without a clutter of combined surgeries and a meeting-ground for the three parts of the Health Service--Consultant, GP, and Local Authority. It benefits the local populations and stimulates local loyalties. Having no need of resident doctors, the General Practitioner Hospitals are economical in medical man-power and the multitude of everyday complaints which fall within their scope will still be with us, demanding much the same type of care well into the twenty-first century. A plan incorporating this pattern of hospitals is comprehensive for the whole gamut of medicine, whereas the Ministry's present plan is merely cohesive for specialist care. Is there yet time for re-appraisal?