Royal Commission on the NHS Chapter 10

Hospital Services

10.1 In this chapter we consider some aspects of the services provided for patients in NHS hospitals. We discuss patient attitudes to the services, government policies on providing hospitals, the problem of ageing hospital buildings and the relationship with the community health services. We deal with hospital dental services in Chapter 9, hospital staff in Part III of the report, the problems of teaching hospitals in Chapter 17, and hospital management in Chapter 20.

10.2 There are about 2,750 NHS hospitals. They range from the large psychiatric hospital with over 1,500 beds and about 800 staff, drawing its patients from a wide area, to the cottage or general practitioner hospital with under 50 beds and a handful of full-time staff providing local service to a small community. The total number of hospital beds is about 480,000, of which 80% are occupied on any one day. Out-patient and accident and emergency departments serve some 100,000 patients daily. Hospital services account for about 70% of total NHS expenditure. They aim to provide a comprehensive range of treatment and care for people who are ill and cannot be adequately looked after in the community.

Services and patients

10.3 Most people rarely have to use hospital services. When they do they are usually at their most vulnerable, removed from the security of their home, dependent on others for their daily living needs and for the treatment which will allow them to resume a normal life. In the main, hospital staff are highly regarded by their patients. This was amply confirmed by the survey of hospital patients’ attitudes which we commissioned from the Office of Population Censuses and Surveys (OPCS) and we draw heavily on its findings in this part of our report.

10.4 The OPCS survey found that the majority of patients were satisfied with the overall service provided in hospital, but there were many detailed complaints and we deal with the most important of these below. We commend the report to all who plan and provide services to patients.

Waiting lists

10.5    Waiting lists in general, and the size of waiting lists in particular, attract a good deal of attention in Parliament and in the press. In the words of an article in The Lancet last year:

“The impression conveyed is that the problem reflects a general one affecting the NHS, due to inadequate resources, money, and beds, to administrative inefficiencies, or to lack of concern by hospital staff.”

Surprisingly, waiting lists attracted relatively little comment in our evidence.

10.6 Discussion of waiting lists seems often to generate more heat than light. There are some basic points to clarify. First, the number of people recorded as waiting for hospital admission is not by itself a useful figure. There are a number of reasons for thinking that it can be misleading, but more importantly it does not indicate by itself how long people have to wait for hospital treatment, especially treatment which they require urgently. The psychological effects of a long wait for admission must not be underestimated, though the OPCS survey found that 80% of all in-patients said that they were not caused inconvenience or distress by waiting for admission.

10.7 Second, interest tends to focus on in-patient admissions, though the waiting time for an out-patient appointment may be just as or more significant. This is because the majority of patients are admitted after they have been seen first as out-patients. There may be a long wait for an out-patient appointment but only a short one for admission as an in-patient. Separate waiting times for out-patient and in-patient are therefore required to give a reliable picture.

10.8 Third, waiting lists are one mechanism for controlling access to services free at time of use. Other countries use other methods, often financial. Immediate admission to hospital for non-urgent treatment implies spare capacity. Waiting lists are likely always to be with us, but that does not mean we should not try to reduce waiting times.

10.9 Generally the acute hospital services provide excellent and rapid treatment of urgent cases. Problems are greatest for non-urgent cases where the longest waiting lists and times are, in the main, for in-patient surgery; and within surgery, for orthopaedics and for some of the commonest operations, for example, hernia repair, and cataract removal. These operations relieve condi­tions which, although not life-threatening, cause much disability and distress. Many are prevalent in the elderly and demand for them will therefore increase in the future.

10.10  Much effort has been put into studying waiting times for admission to hospital. Guidance issued by the DHSS in 1975 referred to a survey which showed that in six major surgical specialties 37% of patients had been waiting longer than a year, nearly 20% for more than two years, and some for four years or more. A number of recommendations were made for reducing waiting times, including pooling of beds and greater use of day surgery. Influences on waiting times include the effect of strikes, longer holidays and shorter working hours for staff. Returns by health authorities to the DHSS in 1976 mentioned shortages of theatre staff, particularly anaesthetists and trained nurses, and theatre facilities amongst the causes of long waiting times. Only limited success was reported in meeting the suggested objective of reducing waiting times for urgent admissions to a maximum of one month and for all patients of one year. Our OPCS survey did not differentiate between urgent and non-urgent cases, but found that 45% of all in-patient admissions took place within one month of the patient being put on the waiting list, but that six per cent had to wait longer than one year.

10.11 There are startling differences in the rate per thousand population on in-patient waiting lists between health authorities, and even between neighbouring districts. The answer to a parliamentary question on 14 March 1978 showed, for example, that in South Camden there were about 73 people per thousand on the in-patient waiting list, while in North Camden there were ten. In Central Manchester health district there were 39 per thousand and in nearby Bury there were six. Other surprising variations can readily be found.

10.12 In view of the importance of out-patient waiting times it is surprising that more information is not available. There has been little research and there are no data held centrally. Our OPCS survey found that 28% of patients waited seven days for their first out-patient appointment and 60% were seen within three weeks. However, 17% waited more than six weeks and of these 44% were distressed by the delay. The main reasons for distress were physical pain or discomfort, and anxiety to know what was wrong.

10.13 There are evidently many aspects to the waiting lists question. We understand that the DHSS have commissioned a large scale study of the subject from OPCS. We have no instant solutions to offer, though it seems clear that methods of improving the position will have to be worked out locally according to the particular difficulties. More day surgery linked to effective community services, better use of operating theatre time, and more cross-boundary referrals may help in some places. A substantial improvement in the position would probably require considerably increased resources of both manpower and finance. Even if the importance of waiting lists is exaggerated, it seems to us that very long waiting times must represent a significant failure in the service.

Out-patient services

10.14 We discuss here both attendance at hospital out-patient clinics and day patient admissions. In the UK the number of new out-patients has remained relatively stable in recent times at about nine million per annum, but there has been a considerable growth in the number of day patients, normally for minor surgery or investigation, who do not stay in hospital overnight. In 1976 there were about 560,000.

10.15 The OPCS survey found that patients’ most common complaints about out-patient clinics were difficulties in obtaining satisfactory information about their progress (25% of all out-patients), and the total time spent in the out-patient clinic (19%). We deal with communication between patient and doctor later in this chapter.

10.16 The fact that only a minority of patients complain does not mean that services are as good as they should be. The OPCS survey showed that 16% of patients waited over an hour to be seen after their appointment time and another eight per cent more than 45 minutes. This is too long, and even though well over half the out-patients were seen within about 15 minutes of the time of the appointment, it seems plain that more effort should be made to arrange for patients to be seen promptly. We recognise that much of the difficulty may be due to overloaded clinics, but the staff manning them should take a realistic view of what they can hope to achieve, and block booking of a large number of appointments at one time should be avoided. Individual bookings waste staff time when patients arrive late or not at all, but this can be ameliorated by appointments for two or three patients at a time. We would like to see investigation into the greater use of evening clinics which would reduce the need for patients to be absent from work and would make more intensive use of hospital facilities.

10.17 We were told that some hospitals keep out-patients on their books too long. The most frequent causes are probably an unwillingness by over­ cautious junior doctors to discharge a patient to the care of his GP, and the lack of a satisfactory review arrangement by the consultant. The consultant should check regularly what goes on in the out-patient department under his name, and the hospital medical divisions should keep in touch with GPs about the balance to be sought between out-patient and GP treatment.

10.18 The OPCS survey did not find that the time taken to get to hospital, whether by the patient’s own means or by ambulance, was a major source of  dissatisfaction. The great majority made their own way and of these 19% spent over half an hour on the journey. However, there were complaints about the time patients had to wait for the ambulance or hospital car to take them home: one in four usually waited an hour or longer.

10.19 As we said earlier there has been in recent years an increase in the practice of admitting day patients. This may be convenient both for the patient and the hospital and may be economical. Both the Royal College of Surgeons of England and the British Hospital Doctors Federation supported the practice and suggested that it might help to reduce waiting lists. Abortion clinics could be provided more widely on this basis. We would like to see more research both on the acceptability of day admissions to patients, and on the benefits to the NHS, and we recommend that the health departments promote this.

Accident and emergency services

10.20 The problems of accident and emergency (A and E) departments stem mainly from their different functions. Some A and E departments have four different functions – dealing with accidents, such as road accidents, involving severe injuries; handling medical emergencies, such as poisoning;  undertaking functions which might otherwise have been performed by a GP; and acting as a clearing house for admitting patients. A and E departments, particularly in large cities, may also have to deal with patients suffering from alcoholism or drug dependence who are often aggressive and difficult to manage. The main questions we consider here are whether A and E departments should perform, in effect, a GP function; and the staffing problems raised with us in evidence.

10.21 In large cities the local hospital has sometimes been used as a walk-in GP surgery by patients who find it convenient to receive their medical attention there. This may discourage patients from registering with GPs, as well as imposing an extra load on the department. The strengthening of GP services in large cities should improve the situation. Meanwhile in certain places it can be a considerable burden: a study of a London casualty department in 1977 showed that 16% of all patients were not registered with a GP, and of the new patients who did not require emergency treatment only 19% had consulted a GP before coming to the hospital. Where the tradition of using the department in this way is strong it may be preferable for the hospital to accept the role and make specific arrangements for fulfilling it rather than to try and resist established local preferences.

10.22 We do not consider that it is practicable to prohibit self-referral since at least some such cases will be genuine emergencies. The OPCS primary care survey suggested that people often had good reasons for going directly to A and E departments. For example, they had gone because they needed treatment for fractures, cuts and bruises; the hospital was better equipped to provide the necessary treatment; or because treatment was needed outside GP surgery hours.

10.23 There have been problems about staffing A and E departments, particularly with doctors. In the past such departments were normally in the charge of an orthopaedic surgeon. However, consultant appointments in the new specialty started towards the end of 1972, and there are now over 120 major departments run by full-time A and E consultants. At present there is a shortage of junior staff, and a high proportion of doctors from overseas. The medical staffing of A and E departments was the subject of a recent report which the Joint Consultants Committee is discussing with the DHSS. We hope that the  result  of these  discussions,   and  the  recent   training  programme established by the Joint Higher Training Committees in medicine and surgery, will lead to improvements in the staffing of these departments.

10.24 A consultant appointment in the specialty may not be justified or In that case the responsibility should be clearly placed with a named consultant in another specialty. We think it preferable to leave to local decision the best way of meeting the demands on A and E departments.


10.25     In this part of the chapter we deal with communications between staff and patients, privacy and wakening times for hospital in-patients. These are not the only subjects of complaint by patients, but they were those on which patients had strong feelings.


10.26    The OPCS survey found that 31% of in-patients and 25% of out­ patients considered that they had not been given sufficient information about their treatment and progress. This was also an issue often mentioned in our evidence. The Royal College of Nursing, for example, told us:

“From the complaints that have come to light through research the most important appear to centre on the failure to give patients and their relatives the right information in the right way at the right time.”

10.27 The OPCS survey suggested that apart from the difficulties of getting information, patients often felt they were ignored. One in four adult in-patients reported that doctors had discussed their condition or treatment with other people “as if they were not there”. Another complaint was of difficulty in understanding what was being said, either because medical jargon was used, or for some other reason such as the doctor’s insufficient command of English.

10.28 About half the in-patients in the OPCS sample said they were not really bothered by not understanding what they were told, but this is certainly not a reason for hospital staff not to make every effort to answer questions which patients have about their condition or treatment. And though it may be important for teaching purposes for a consultant, for example, to explain to students what is wrong with a patient, it is grossly inconsiderate for this to happen without the patient having been consulted. It is also essential for patients and relatives to be seen at times in private. A busy corridor or ward waiting room is not acceptable and we recommend that all hospitals should provide facilities for this purpose.

10.29 Another point about communications made in our evidence was that more general information about the hospital and its routine should be made available to patients. The OPCS survey showed that about 60% of in-patients were given an explanatory booklet or leaflet about the hospital either before they were admitted or soon after, and nearly all of them had found it useful. The main complaints about the booklets were that they did not contain enough information, or that the information they did contain was wrong. The survey showed that many patients would have liked to have  information about facilities at the hospital, for example shops and day rooms; and the parents of children going into hospital would like to have known whether they should take their child’s own clothes and toys with them. This seems to be a simple and necessary requirement, and so much more easily conveyed in a booklet than by waiting for patients to ask, and we recommend that all hospitals should provide explanatory booklets. They should also include information about the suggestions and complaints procedures. Whenever possible admis­sions should be planned with the patients. Once in the hospital, patients should also be told what is going to happen to them, for example when and why they are being X-rayed or having blood samples taken.


10.30     Many patients feel strongly about the privacy they are permitted in hospital. We were told by the Western Provident Association:

“Our experience leads us to believe that one of the principal reasons (perhaps the strongest) which leads people to subscribe to Provident Associations is to ensure the privacy of their own room when in hospital.”

The OPCS survey found that 11% of in-patients would have preferred on a future occasion to have a room on their own, compared with over 60% who would favour a small ward. It may of course be that the Provident Associations are supported by people who feel particularly strongly about having their own room in hospital, and who do not make use of the NHS for that reason, or it may be that actual experience of hospital changes one’s views.

10.31     The OPCS survey recorded that:

“over half (52%) of the 74 patients who, given the choice, would opt for a room on their own said this was because it would be quieter. Preferring not to see other ill people or hear about their complaints or operations was mentioned by 18%, and one in four admitted to simply preferring their own company or not being particularly sociable. More privacy was a deciding factor for a considerable proportion of patients (20%) either when being examined or treated or when visitors were there, and a small number of informants thought there was more freedom for patients in single rooms – visiting arrangements would be more flexible, they could choose which TV programme to watch, and so on.”

10.32     There are probably other reasons why patients prefer their own room, and it seems to us that the NHS should aim so far as possible to meet this preference. In some modern hospitals a high proportion of beds are in single rooms or small wards, but in older hospitals larger wards may be the rule. Amenity beds in single rooms or small wards are sometimes available at a charge which has, since 1 August 1975, been £3 per day for a single room and £1.50 for a bed in a small ward, for patients who prefer privacy. There are roughly 4,000 amenity beds, but not all hospitals can offer them. Amenity beds are not bookable before a patient goes into hospital, and may have to be vacated if they are required for urgent medical reasons by another NHS patient. All the patient is buying for his £3 is privacy: his treatment and amenities are the same as those provided for other NHS patients in the hospital.

10.33 Although authorisation of amenity beds is freely given by the health departments, both the number and their occupancy have been falling steadily. They represent under one per cent of hospital beds at present, and not all of those are in single rooms, though we have seen that 11% of patients would prefer their own rooms. The reason for the disparity would seem to be a combination of the rooms not being bookable in advance and few patients knowing of their existence. One argument against meeting these points is that to do so would create separate waiting lists if the demand outstripped the Other possible reasons are that the physical separation of amenity beds might create additional work for nursing staff, particularly in times of staff shortages, and that patients might have unrealistic expectations. Whatever the reasons, we understand that there has been a marked reluctance on the part of hospital management to publicise the availability of amenity beds.

10.34 This attitude seems to us to be absurd. If amenity beds are to be provided under the NHS then their existence should be made known to the public in the same way as other facilities provided. If there are shortages, that should be explained also. If this results in pressure for more amenity beds to be provided, then steps should be taken to meet this demand. We see nothing wrong about waiting lists for amenity beds developing; this is a matter of patients’ personal preference. There may be places where staffing or other considerations make the provision of amenity beds impracticable, but that does not mean that they should not be provided where they can be. The phasing-out of pay beds should have made amenity beds more available. We recommend that hospitals should ensure that their availability is routinely made known to patients when they are given a date for admission.

10.35 Another aspect of the question of privacy raised in evidence was mixed sex wards. Some patients find it embarrassing to share wards with members of the opposite sex. There may be occasions when the efficient provision of services requires mixed sex wards, but there cannot be very many, and patients should be given the choice.

Wakening times

10.36 The OPCS survey found that nearly half the patients surveyed complained of being woken too early. This is scarcely surprising when 44% of patients were being woken before 6 am, and 76% before 6.30 am. We have singled the problem out because so many patients evidently find this aspect of hospital life unsatisfactory.

I10.37 n 1961 a sub-committee of the Minister of Health’s Standing Nursing Advisory Committee produced a report on the pattern of the in-patient’s day. The opening sentence of the report was “In many hospitals the patient’s day begins sometimes between 5 am and 6 am” It is evident that there has been all too little improvement in the last 18 years. Obviously some people are used to getting up early and to do so is no hardship, but equally obviously it is a hardship for others. There seem to be a number of reasons for early wakening – the amount of work expected of night nursing staff before they go off duty and the timing of the changeover of shifts, often controlled by the availability of public transport; medical rounds; medicine rounds and the need to collect laboratory specimens; and the design of the ward (Nightingale wards tend to mean “one awake, all awake”). Tradition probably plays a part in the hospital routine also.

10.38 This seems to us a prime example of the hospital being run for the convenience of the staff rather than the patient. We do not believe that the in-patient’s day cannot be so organised that the majority of patients are able to wake up at roughly their usual time. We have seen the latest report on the organisation of the in-patient’s day which discusses the problem. We would like to see a much tougher line being taken on this matter, and we recommend that health authorities should review forthwith the practice in the hospitals for which they are responsible.

Provision of Hospitals

10.39 In general it is no easier to define the need for hospital care than the need for other health services. It varies over time and from place to place. However, the demand – as opposed to the need – for hospital care is largely determined by GPs who are responsible for most out-patient referrals. In doing this they  may  be  influenced  by  such  factors  as  the  availability  of other appropriate institutional or community care, the expectations of individual patients, and waiting times for admission to hospital.

10.40 There are other problems in working out a strategy for providing hospital services. In 1948 the NHS inherited over 3,000 hospitals, mainly old, inadequately equipped and badly distributed. The process of replacing and redistributing hospital services involves heavy capital expenditure, but succes­sive economic crises have interfered with and modified strategic planning. The effective planning of hospital services is of major importance. Health authori­ties must be chiefly responsible for determining their own requirements and will need good information about the state of hospital stock, morbidity, local population trends and the effectiveness of methods of treatment. They will also
need to consult interested local authorities.

10.41 In this section we consider the health departments’ policies on the provision of hospitals. We concentrate on England and Wales. In Scotland and Northern Ireland, policies seem to have been applied more flexibly with local solutions being preferred. There may, however, be messages in what we say about England and Wales for the other parts of the UK.

District General and Community Hospitals

10.42    In England and Wales the district general hospital (DGH) has been the basis for hospital planning since the Hospital Plan was introduced in 1962. Its role is to provide a full range of specialist services, but different views have been taken of how many beds and what services. The 1962 Hospital Plan proposed 600 to 800 beds as the normal size for a DGH serving a population of 100,000 to 150,000. Subsequently the report of the Bonham-Carter Committee proposed 1,200 to 1,800 beds serving a population of 200,000 to 300,000, based on the view that DGHs should be planned around teams of not less than two consultants in each of the major in-patient specialties.

10.43     In addition the Bonham-Carter Committee envisaged a need for a number of linked small hospitals to be responsible for:

“the continued in-patient care of local patients who have already been assessed and treated by a consultant at the district general hospital, and who in the consultant’s judgement no longer need specialist medical attention but still need nursing beyond what can be provided in the community”.

10.44    Current strategy in England and Wales is to provide a network of 250 DGHs supplying:

“a full range of specialised treatment, and including a maternity unit, a psychiatric unit, a geriatric unit containing at least half of the district geriatric beds, and a children’s department, as well as specialised surgical and medical facilities. Some, but not all, DGHs would have accident and emergency units, and some would have in-patient units for ENT and ophthalmology. Some would also provide regional specialties (such as neurosurgery).”

The DGH would be supported by community hospitals and ideally be on a single site to facilitate the provision of laundry, pathology and other common services. Where this is not possible the DGH is composed of linked local hospitals. In some places completely new buildings are required, and a “nucleus hospital” is being developed by the DHSS to provide a range of standard departments selected to suit local needs. The nucleus hospital would be of about 300 beds and would be capable of expansion later on up to the now preferred range of 600-900 beds. It is being designed with economy in capital and running costs as a prime objective.

10.45    The elderly are important users of hospital services but many of them, and indeed other patients, do not require the full specialist facilities of a DGH. Instead it is envisaged that community hospitals of between 50 and 150 beds serving a population of 30,000 to 50,000 would provide a limited range of services, in smaller units and nearer patients’ homes, under the care of general practitioners. The Priorities Consultative Document for England said:

“up to a quarter of all in-patient beds and many day places might eventually be in community hospitals. It is intended that up to two-thirds of community hospital beds should be for geriatric patients and for elderly patients with severe dementia. The remainder would be medical or post­operative surgical patients including pre-convalescent cases transferred from the DGH.”

Since the issue of the Consultative Document in 1976 additional functions, such as minor and intermediate surgery, and radiology and other diagnostic techniques, have been assigned to community hospitals. There has been great difficulty in getting this approach accepted in the NHS, and very few community hospitals have been established.


10.46    Although it is generally agreed that DGHs should be responsible for the delivery of specialised services, they have disadvantages. The TUC, for example, in their evidence to us pointed out:

“There is a limit, however, beyond which the general hospital becomes too large and impersonal and the sheer physical distances within the hospital become too great.”

The larger the DGH, the greater the population served, the more serious the problems of communication within it and of access to it are for patients and staff. The size of the hospital will also affect capital and revenue costs.

10.47 The optimum size for a DGH has yet to be determined, but a range of sizes, to take account of local conditions and needs, will probably be The “nucleus hospital” approach looks to offer the greatest flexibility in response to what are certain to be changing needs. We believe that increasingly the human aspects of hospital size, such as good communications, building up group loyalties and good industrial relations, will be seen to be important for both patients and staff. These are matters which need to be researched.

10.48 Most of the criticism of the present hospital policy in England and Wales centred on the community hospitals. There was support for having small local hospitals manned by GPs, but concern that such hospitals would simply turn into long-stay units for the elderly, a high proportion of whom would be severely mentally infirm. There is no dispute about the need to provide for these patients, whose numbers are increasing, but fears were expressed about the staffing implications of transferring them from the mental hospitals into community hospitals, in the care of GPs.

10.49 The development of nursing homes mainly staffed and run by nurses, might, we consider, make a useful contribution to the problem. Some small hospital might be converted to nursing homes, others might be purpose-built. They could reduce the number of dependent elderly patients who require little but nursing care in local hospitals, but they would make heavy demands on the nurses who staff them and this must be recognised. Nursing homes are already widely used on the continent and, as we said in Chapter 6, there should be more experimentation in this country. The increased use of nursing homes for elderly or chronically disabled patients would leave more scope for GPs to look after their other patients who need only the limited facilities a cottage or GP hospital can offer. We understand that the DHSS is reviewing their policy on community hospitals, and we hope they will take these factors into account.

Acute hospitals

10.50 The main debate about acute hospital services has centred not on their quality but on the amount of resources devoted to them. The specialist general hospital services are well distributed over the country and their quality is high. Our evidence contained much praise and little criticism of them, and we endorse the view of their contribution that this implies. The man, woman or child who becomes acutely ill in this country is well cared for.

10.51 Not surprisingly, those who work in the acute services tend to believe that too few resources are allocated to allow them to sustain, far less enhance, the quality of treatment and care of the acutely ill. Those who work in the services which are currently given priority consider that acute services have been too favoured, that too much attention has been given to cure and too little to care, and that the less dramatic and more persistent conditions of illness and disability have been neglected. We do not propose to judge between these views, but we would be unwilling to see a redistribution of resources occurring at the cost of reducing the quality of acute services.

10.52 Elsewhere in our report we deal with the deficiencies of the hospital capital stock, unit management, medical and nursing careers, teaching and non-teaching hospitals, professional advisory structure, and other matters which immediately affect the services provided by acute hospitals. We hope we have made some contribution to solving their problems, and indeed those of peripheral hospitals which we next discuss.

Peripheral hospitals

10.53 The particular problems of teaching hospitals are discussed in Chapter 17. They have received a good deal of public attention and much of our evidence related to them. However, the problems of the non-teaching or peripheral hospitals are at least as serious. Many of the buildings are very old, the facilities are poorer than those in the teaching hospitals, and they are less generously staffed. Nonetheless, they provide the bulk of care and treatment up and down the country.

10.54 The redistributional effects of the Resource Allocation Working Party approach   to  resource  allocation  will   normally  work  in   favour  of peripheral hospitals, and the health departments have, with the support of the central  medical  manpower  bodies,  been  endeavouring  to secure  a  better distribution of medical training posts. The increasing use of non-teaching hospitals in undergraduate medical education is to be welcomed and encour­aged, but more teaching facilities and staff will be required if this development is to be fostered. Pressures of work may mean that staff in these hospitals find it difficult to take study leave, and while the needs of the service must of course be placed first, a more generous attitude on the part of health authorities may pay long-term dividends. Measures of this kind will help to break down “us and them” attitudes of staff in hospitals which have in the past been separately managed and financed but which with recent educational develop­ments have become less distinct from the traditional teaching hospitals.

Mental illness hospitals

10.55 In England and Wales there has been a departmental policy to run down and close mental hospitals, replacing them with other facilities. The 1962 Hospital Plan stated that “there will be no place for many of the existing mental hospitals … a large number will in course of time be abandoned”. It was expected that 13 mental hospitals with over 400 beds each would be closed by 1975. In fact only one large hospital for the mentally ill has been closed in England and Wales, and it has been converted to the care of the mentally handicapped.

10.56 The 1962 Hospital Plan was based on statistical projections of mental hospital populations rather than on a major breakthrough in the prevention or cure of mental illness. There has certainly been considerable progress in treatment, and the number of mental hospital in-patients in England and Wales has fallen from nearly 150,000 in 1955 to 80,000 in 1977. But major mental illnesses, such as schizophrenia, and the dementias of old age, still present intractable problems, and the numbers of the very old and demented are rising steadily in the population, both inside and outside the

10.57 It was  hoped  that  the  mental  hospitals  could  be  replaced  by psychiatric units placed in DGHs, supported by small local in-patient units and generally by an enhanced provision of services in the community. The feasibility of this has not yet been demonstrated. The relatively small size of the DGH units, the lack of money to create many more of them, and the nature and extent of the patient populations which the psychiatric services have had to continue to look after, have frustrated the departments’ plans. Some DGH units have been selective either in their admission policies or about those for whom they would continue to care, and the mental hospitals have had  to  receive those  patients  whom  the  DGH  units  have  thought  were unsuitable in the first place or whom they had failed to cure.  In-patient facilities in community hospitals and hostels have not materialized. As we have noted, little or no progress has been made in developing community hospitals, and we understand that only one district has a “hospital hostel” for the long-stay mentally ill.

10.58 The departments’ plans have depended heavily also on increased provision for community care by local authorities. Despite a sustained drive to discharge to and maintain mentally ill people in the community, the build up of the necessary social services has been slow. The provision of day centre places in particular has fallen far behind expectations. The capacity of local authorities to develop services, and in particular residential accommodation, for those who are considerably mentally disabled or disturbed may have been over-estimated. Local communities have not always welcomed such develop­

10.59    The DHSS told us that its 1975 White Paper made clear that the closure of mental illness hospitals is not now an objective of their policies:

“We welcome this opportunity to stress that our aim is not the closure or rundown of the mental illness hospitals as such; but rather to replace them with a local and better range of facilities.”

And again in its Priorities Consultative Document:

“The closure of mental illness hospitals is not in itself an objective of Government policy, and the White Paper stresses that hospitals should not encourage patients to leave unless there are satisfactory arrangements for their support. The possibility of closing a hospital depends both on the existence of the necessary range of health and local authority facilities, and on the length of time for which care must be provided for the hospital’s remaining long-stay patients.”

We do not find these statements an unambiguous declaration of policy; and probably most of those who work in mental hospitals in England and Wales still believe that they are to be closed at least in the long run. There have been other consequences of a policy which has been unclear or has not been carried through. New hospitals have not been built and old ones have been inadequately maintained and upgraded. Critics and pressure groups have been encouraged to believe that mental hospitals must have harmful effects on patients and should be abandoned. For example MIND told us:

“Better services for the mentally ill will only be achieved if within the next 10 years we can look forward to the phased closure of the majority of isolated psychiatric hospitals.”

It is not surprising that the morale of staff in these hospitals has been damaged, and recruitment to what have seemed to be condemned relics of the past has been affected.

10.60    We are certain that there is a continuing need for most of the mental illness hospitals, and we recommend that the health departments should now state categorically that they no longer expect health authorities to close them unless they are very isolated, in very bad repair or are obviously redundant due to major shifts of population. It should be made clear that they will be required throughout the remainder of this century and for as long ahead as it is possible to plan.

10.61 The placing of psychiatric units in DGHs was a notable development in that it brought the psychiatric services into the main stream of medicine and made provision for the care of mentally ill people who might not otherwise have been willing to seek treatment. But the creation of these units, dealing mainly with the acute and more easily treatable problems, has led to what amounts in many places to a two-tier service a first-rate service, for the acutely ill and a second-rate service for the remainder; and to such resentment in the mental hospitals. It is evident now that both mental hospitals and DGH units are essential to a well-balanced psychiatric service. We suggest that not all acute services should be provided in the latter: there should be some specialisation of function between the two but not entirely on the basis of short or long term treatment and care. Some at least of the staff might rotate between the two institutions or work in both, and both should be used for training and share out-patient and other community facilities.

10.62 Some patients need to be restrained for their own effective treatment and safety or, less often, for the protection of the public. All large mental hospitals should provide for this, and the hospitals should feel confident enough in their purposes and integrity to be able to strike the right balance between freedom and constraint. The prison services are now having to look after a good many men and women who are suffering from an identifiable mental illness, who should be in psychiatric care and are not sufficiently disturbed to require admission to a Special Hospital such Broadmoor. It is the mental hospitals which should take such cases. Some consultants have refused to do so on the grounds that these people are not susceptible to treatment and so do not need their specialist care. Some of the nursing staffs of these hospitals also have been ambivalent towards, or antipathetic to, receiving such patients. It is often said that society has become more violent in its behaviour both outside and inside hospitals; in hospitals it is the nursing staff who receive the brunt of this violence. Despite professional codes of practice, nurses have still felt uncertain about how far they are entitled to restrain violent behaviour, in face of critical public opinion bolstered by well-publicised cases of staff assaults on This is an area of practice where strong medical and nursing leadership could enhance morale and raise levels of tolerance. The provision of regional secure units will provide a valuable base for improving practice through training and research, but they should be introduced on an experimental basis before being generally introduced.

10.63 We realise the great difficulties which those working in mental hospitals have had to face in the past decade or more, with an uncertain future, shortages of staff, a greater degree of patient dependency because of the increasing numbers of old people, and often poor facilities. We believe that given the necessary encouragement and practical assistance they can fully recover their self-confidence.

Mental handicap hospitals

10.64    We have dealt with the provision of services for the mentally handicapped in Chapter 6 and will discuss in Chapter 16 the possibility of these services becoming the responsibility of the local authorities. In addition we are conscious that consultation on the recent Jay Committee report has only just commenced. Here we look briefly at the future of the mental handicap hospitals.

10.65 The position of the mental handicap hospitals is similar in many respects to that of the mental illness hospitals, but there is greater scope for contraction since they have had to care for large numbers of people who did not need hospital care or treatment but were rejected by society. In addition, although the mental handicap hospitals have a growing geriatric population they are not under the same pressure as the mental illness hospitals to admit geriatric cases from the community.

10.66 It seems clear to us that hospital provision will continue to be required for many mentally handicapped people, both children and adults. The Development Team for the Mentally Handicapped classified those in residential care into four groups. Group IV was composed of those with “severe double incontinence, multiple physical handicaps, severe epilepsy, extreme hyperkinetic [i.e. overactive] behaviour, aggression to self and others”. The proportion of hospital residents in this group was 54.3% for adults (with 3.5% over 65) and 68.3% for children. Severely mentally handicapped people lack basic self help and self preservative skills and have little verbal capacity. The prospect of transferring these patients to community care seems remote. There is therefore much to be done, in nearly all these hospitals, to make the environment more suitable both for long-term care and for active rehabilitation. It must not be forgotten that for many of these patients, the hospital is their home. The fact that these hospital patients are becoming more disabled, and so more demanding to care for, imposes increasing strain on the staffs looking after We are conscious of the recent concern about the standards of care and treatment in some of these hospitals and we comment on this in Chapter 19. It is clear that the staff should be supported in every way: by being given good working conditions and equipment, and the opportunity to keep abreast of the latest methods of treatment and care, through the provision of study leave and secondment; and they should if possible work both in the hospital and in the community parts of the service.

Hospital Buildings

10.67 We noted above that the process of replacing hospitals had been slow, and the strategy subject to variation. Professor Abel-Smith has remarked that:

“Compared to some other advanced countries, particularly those that have enjoyed higher rates of growth, the task of renewing hospitals or replacing them with more appropriate places of care was started late.”
Because piecemeal upgrading and renovation has been carried out in many hospitals, it is misleading to talk in terms of “new” and “old” hospitals, but in England probably about one-third of hospital beds are provided in new or converted accommodation built since 1948. The proportion is higher in Northern Ireland, but lower in Scotland and Wales. On the other hand, a survey undertaken in England of the age of hospitals showed that over one-third of the stock, in terms of floor area, had been originally built before the turn of the century, and that the average age in 1971 was over 61 years.

10.68 Although we do not have reliable information about the age of the hospital stock of other advanced countries, we were told in evidence that generally hospitals in Europe and in North America are expected to have a life of only 25 to 40 years. This was largely confirmed by our experiences abroad; for example in Schleswig-Holstein in West Germany all hospitals built before 1955 will have been replaced by 1982. If this rate of replacement had been accepted in the UK about three-quarters of existing NHS hospitals would already have been pulled down and replaced.

10.69 It should not be assumed that because a building is old it is Hospitals put up 50 or 60 years ago were built to last and the fabric may often be perfectly sound. The case for replacing a hospital building is not made when it has been established that it was erected before the introduction of the health service, or even before the turn of the century. The UK is not so wealthy that it can afford to scrap perfectly usable hospitals merely because they are getting old. We should be aiming at making the maximum use of what we have got, and this will often mean adapting, upgrading and extending rather than replacing.

10.70 On the other hand, there may be difficulties in adapting old buildings to modern technology and it may be cheaper in the long run, and better for patients, simply to replace them. Movements in population may have reduced the usefulness of a building in a particular place. For example, it was recognised before the first world war that London was over-provided with hospitals and although a number have been moved out of the centre, the problem is still with us. Elderly buildings are also often gloomy, though they have no monopoly of this, and in many cases, particularly in those for long stay patients, facilities such as kitchens may be antiquated. It hardly needs saying that despite inconvenient, depressing and difficult surroundings the vast majority of hospital staff are giving devoted service to their patients. We visited, for example, a surgical ward, overcrowded and squalid, and yet found nurses and other ward staff cheerfully efficient and surgeons doing excellent work. The replacement or upgrading of such old buildings should lift the spirits both of those who work in and those who use them.

10.71 One aspect of the present position that should be noted is the priority which has been given to acute and maternity services since 1948. For example in England, only 12% of hospital accommodation for mental illness (measured in floor space) has been provided since 1948, 23% of geriatric accommodation and 27% of mental handicap, against 35% for acute units over 200 beds and 44% for maternity.

10.72 It is difficult to prove that a particular sum is required to replace our hospitals. A complicated balance has to be struck between the kind of factors referred to above. It should also be remembered that it takes at least ten years to design and build a large hospital by which time there may have been changes in the population served, the other facilities available and medical technology. However, many of those giving us evidence felt strongly that greater funds should be made available to rebuild our hospitals.

10.73 Launching a “crash programme” to modernise our hospitals is often suggested. The idea is that the government would set aside much larger sums of money than have so  far  been  available,  earmarked  for  NHS  capital development, to be spent over a relatively short period. Once the programme had been completed, capital spending would return to its previous level. Unfortunately, it is not merely a question of making money available, though of course that is an important consideration. A large and rapid expansion in the hospital building programme would make heavy demands on the architects and engineers employed by health authorities and the building and engineering Furthermore, if the new buildings are not to be wasted, it would be necessary to take account of the consequences for revenue expenditure and reappraise existing plans for health and community services which would have been prepared on the assumption of a lower level of capital expenditure.

10.74 Despite the  uncertainties  and  difficulties alluded to  above   we recommend that the government should find extra funds to permit much more rapid replacement of hospital buildings than has so far been possible; and, more important, they should stick to their plans. The constant delays and shifts of policy so that a hospital promised is long delayed and then has to be modified or scrapped or cannot be opened because of lack of resources, inevitably leads to staff and public becoming bitter. We hesitate to call it a “crash programme”, but we think a planned programme of replacement and upgrading is needed over the next 15 years. This should be a top priority which needs to be tackled jointly by the departments and health authorities, in consultation with local authorities. Initially the emphasis should be on the oldest and worst facilities, whether they are for acute or long-stay patients. We have concentrated on hospitals but what we say applies equally to other NHS

Hospitals Community Relationships

10.75 We conclude this chapter with a brief discussion of some aspects of the relationships between hospital and community health services. From the patient’s point of view it is most important that these services should operate in an integrated and consistent way. The services should be provided so that the patient can move easily from being cared for in the community to hospital, and as he improves, back to the community. This requires good communications between those who work in hospitals and those who work in the community, and some overlap between what might be considered the spheres of responsibility of staff who are hospital or community based. The rehabilitation services exemplify some of the difficulties particularly well. Elsewhere in the report we deal with aspects of community and hospital care, and the relationship between health and local authority services.

10.76 The reorganisation of the NHS was, of course, intended to integrate health services in the community with those in hospitals, but at working level, with which the patient is concerned, the effects will often not have been felt. The employer may be the same but health service workers in the community and in hospitals may still go their own way. The NHS depends heavily on the personal social services – social workers, home helps, etc – provided by local authorities, and is affected by other local authority services, such as housing and education. Close links between the NHS and local authority services are therefore just as necessary as those between hospital and community services.

10.77 There is frequent criticism of communications across the hospital/ community boundary: hospital staff complain of patients being referred to them without adequate documentation, and GPs complain of patients being discharged to their care without warning or information. While there are well established conventions  between  doctors  for  handing  over  a  patient  from hospital to community, or vice-versa, the development of such conventions between nursing staff has been slow. This seems to us to be a point worth following up.

10.78 There are   already   arrangements   for   certain   community   health workers to work in hospitals and hospital workers to work in the community. In Great Britain about 9,000 GPs work for a session or two each week in hospitals, and the introduction of the hospital practitioner grade should make hospital work more attractive in future. There has long been provision for a consultant to visit a patient at home at the request of his GP, but the value of such visits will be reduced if there is no proper consultation between GP and consultant at or after the time of the visit.  There is provision, also, for consultant sessions to be held in health centres, though the consultant often cannot function to maximum efficiency without the support of his usual staff and specialist facilities.

10.79 There is   little   cross-boundary   working   by   other   health   service Some psychiatric nurses based in a mental hospital may provide a community  psychiatric   nursing   service  for   discharged   patients   and   some successful liaison posts have been developed by district nurses and health visitors. In some local hospitals, nurses work both in the hospital and the community. Such developments need to be evaluated and the results made widely known. In addition, some hospital based occupational therapists and physiotherapists undertake domiciliary work, and speech therapists and those concerned with the deaf may be employed either in hospitals or the community, but rarely in both. The need to co-ordinate the flow of information between professionals in the interests of the patients remains all the more important.


10.80 Many patients who leave hospital not completely well are capable of looking after themselves with minimal assistance from community workers, and the help of relatives or friends. However, the division between hospital and community services will be particularly important for patients who require long-term rehabilitation. We commissioned a paper from Mildred Blaxter of the MRC Medical Sociology Unit in Aberdeen on the principles and practice of rehabilitation. Her revealing paper, which is reproduced at Appendix G, drew attention to some of the difficulties. She quoted the results of a previous study:

“The consultants observed by Forder et al. assumed, quite wrongly, that the GP would ask for advice if he needed it; they assumed, quite wrongly, that the patient’s circumstances and family would be already known by the GP; and they assumed, quite wrongly, that the GP would see himself as having a co-ordinating function, and would ensure that rehabilitative and community services swung into action.”

Often responsibility for the patient’s employment, etc. after leaving hospital remains substantially in the hands of the consultant.

10.81 Mildred Blaxter drew attention also to the dilemma that while the hospital consultant whose “short-term responsibility for the patient and a limited knowledge of his life circumstances, has unlimited power to prescribe therapies, aids and appliances”, the general practitioner “with long-term responsibility and potentially better knowledge is unsure of his responsibilities and limited in his access to services”. She stressed the importance of the GP being given better facilities and permitted more responsibility for referral to specialist therapies, a view which we would support. This will be particularly important if day-care rehabilitation centres are to be further developed.

10.82 There are a number of other problems in providing rehabilitation services apart from those referred to above. The division between community and local authority services to which we have already drawn attention, and between local authority and voluntary services, give rise to further problems. In particular, the complexity of the various rehabilitation services, and the financial support available, hinder action and themselves generate problems. Mildred Blaxter told us:

“The ludicrous situation has now been reached where the regulations for the conglomeration of benefits, compensation, pensions, special allow­ances, discretionary payments, and so on … fill a fat book.”

These divisions were also given as a “major cause of the general dissatisfaction about the aids, appliances and domestic adaptations provided for disabled people.” Clearly the need for effective rehabilitation services will increase in the future as provision for caring for patients in the community is further expanded. It seems to us that this must be an important factor in future NHS planning.

10.83    The problems in the relationships between hospital and community health services are not instantly resolvable. Some of them may be ameliorated by the recommendations we make elsewhere. For the rest, we stress their importance to the patient but must leave others to pursue their solutions.

Conclusions and Recommendations

10.84    Most patients are well satisfied with the treatment they receive in NHS hospitals as they are with other parts of the service, but there were two grumbles which were both frequent and long-standing. Patients are not given enough information about their treatment, and despite constant complaints over the years they may still feel they are ignored when doctors discuss them with colleagues. Hospitals persist in waking patients at the crack of dawn.

10.85 We did not hear a great deal about waiting lists in our evidence, and our OPCS survey found that most patients were not caused great distress by waiting for admission to hospital. The significance of waiting lists has certainly been exaggerated, partly for political reasons, and it is waiting times which should in any case attract attention. The DHSS have now commissioned a large scale study on the subject and this may throw more light on the matter.

10.86 We have no quarrel with the DGH approach to providing specialist services, though flexibility is plainly required. We think the “nucleus hospital” approach is sensible. There is still dispute over the best use of the many small hospitals which are not part of the DGH. It is clear that the community hospital approach is not acceptable and we were relieved to hear that the DHSS are rethinking the present policy. There is plenty of room for experiment in this as in so many other parts of the NHS, and we would deplore too rigid an approach. The development of nursing homes could make a major contribution to the care of the elderly.

10.87 Acute hospital services are generally excellent. Most of them are provided by peripheral non-teaching hospitals, often in old buildings ungener­ously staffed. We hope that our recommendations will improve the position of both those who use them and those who work in them.

10.88 We think the mental illness hospitals need to be rescued. Despite the statement in the DHSS Consultative Document on Priorities, there is a widely held view that the specialist mental hospitals are to disappear. There is no sign of our being able to dispense with them in the foreseeable future. The development of acute psychiatric units in DGHs, itself an admirable develop­ment, has tended to leave the mental illness hospitals with the chronic and most difficult patients. They need to be clearly reassured about their future, to be integrated fully into a unified psychiatric service, and to receive a proper share of capital monies.

10.89 Finally, communications between the hospital and the community services are not all that they should be and the arrangements for community workers to work in hospitals and vice-versa need to be improved. Strong links are particularly important in the rehabilitation services.

10.90 We recommend that:

  • the health  departments should  promote  more research  both on the acceptability of day admissions to patients, and on the benefits to the NHS (paragraph 10.19);
  • all hospitals should provide facilities for patients and relatives to be seen in private (paragraph 10.28);
  • all hospitals should provide explanatory booklets for patients before they come into hospital (paragraph 10.29);
  • hospitals should ensure that the availability of amenity beds is routinely made known  to  patients  when  they  are  given  a  date  for  admission (paragraph 10.34);
  • health authorities should review forthwith wakening times for patients in the hospitals for which they are responsible (paragraph 10.38);
  • the health departments should now state categorically that they no longer expect health authorities to close mental illness hospitals unless they are very isolated, in very bad repair or are obviously redundant due to major shifts of population (paragraph 10.60);
  • the government should  find  extra  funds  to  permit  much  more  rapid replacement of hospital buildings than has so far been possible and they should stick to their plans (paragraph 10.74).