Back to the future

A couple of years ago, I let in numerous goals playing football
with some young people. They advised me to retire on grounds of
age. Fair enough, but being old does mean that I can look back and
see the folly of reinventing policies that have previously failed –
like foundation hospitals.

Before 1939, most hospitals were run by voluntary bodies or local
authorities. More than 1,000 voluntary hospitals, with income
raised from private donors, fund-raising events and fees, had
independence and prestige. They were the foundation hospitals of
their time. They attracted the best qualified doctors, bought
modern equipment and were supported by the kind of people listed in
Who’s Who. They did train doctors and did develop new
techniques but, in terms of service to the nation’s health, they
had drawbacks.

Their higher salaries enabled them to recruit trained nurses to the
detriment of other hospitals. Independence allowed them to choose
short-term patients who could be cured rather than long-term
patients who filled up beds. The best voluntary hospitals were
unevenly spread. Bad luck on those areas without them.

Local authority hospitals were twice as numerous and in the hands
of elected councils. Those with the money and will did develop some
hospitals with a range of specialist departments. But nearly all
tended to be loaded with emergency admissions and the long-term
sick. That, together with a shortage of nurses, resulted in some
hospitals having no trained nurses and wards that contained nursing
mothers, babies and senile patients. Britain was characterised by a
two-tier system with the independent, voluntary hospitals providing
adequate care for patients of their choice while leaving the local
authority hospitals to cope with the rest.

The second world war, with its bombing casualties and numerous
evacuees, exposed the deficiencies of the system. The hospitals
were in the wrong places and lacked staff with the required skills.
The Labour government’s National Health Service Act 1946 abolished
the two-tier system by nationalising most hospitals. They were then
centrally financed and organised on a regional basis. The aim was
to spread hospital care to where it was needed with access not
depending on the whims of hospitals or the ability to pay. These
aims were never fully achieved but the new system was an enormous

More than 50 years later, another Labour government is creating
foundation hospitals which are to be almost independent, free to
borrow money and empowered to set their own salary levels. Health
secretary Alan Milburn wants 300, chosen from the existing best
hospitals, within five years.

Criticisms have been numerous. Dr Ian Bogle, chairperson of the
British Medical Association, foresees “a two-tier service in which
patients who live near foundation hospitalsÉreceive better
services than those who are treated in other hospitals”. Labour
backbenchers are worried that the elite foundation hospitals will
attract ever more qualified staff. Other hospitals, already
referred to as “sink hospitals”, will struggle to retain nurses and
doctors and will be left with the bed-consuming cases. In many
ways, it is a return to the deficiencies of the pre-war

One of Milburn’s chief arguments is that the control of foundation
hospitals will be transferred to communities with most members
elected locally. The small print is that the voters will be
self-selected – that is residents or patients who register
themselves to vote, rather than the whole population. As an
editorial comment in the British Medical Journal put it:
“The first safe prediction therefore is that the membership will be
unrepresentative.”1 It is back to control by the
Who’s Who types again.

I spoke to a much respected GP who is devoted to medical care in
Easterhouse, the Glasgow community in which I work. He is relieved
that the Scottish executive has rejected Milburn’s scheme but he
points out that a two-tier system already exists with the NHS
coping with chronic cases while private hospital care flourishes as
more patients buy operations to avoid waiting lists.

Foundation hospitals, he says, will accentuate this division as
they will also want to tap into the private market. Already the
chief executive of University Hospital Birmingham Trust anticipates
“the opportunity to develop larger private practice facilities”.
Will foundation hospitals eventually be in the grip of the private
market? At least that did not happen in the 1930s.

1 BMJ, 25 January

Bob Holman is the author of Champions for Children: The
Lives of Modern Child Care Pioneers, Policy Press,

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