General practitioner hospitals: coming or going?

Papers in the last four weeks' issues of the BMJ raise again a question which has smouldered since the early 1960s. At that time the Department of Health's policy favoured the elimination of small, peripheral hospitals and the concentration of acute services in large, central district general hospitals. Opinions on the place of general practitioner hospitals still differ, but these four papers show not only that they are still surviving but also that they can provide a real service to the community and to general hospitals-if they are effectively managed. Firstly, North and others (21 April, p 1209) described a pioneering 24 bed hospital in a deprived urban area. It has no outpatient or diagnostic facilities and no regular consultant visits but emphasises facilities for rehabilitation and maintenance of patients (especially the elderly) in the community. The authors estimate that almost half the patients would have occupied a bed in a district general hospital had the new hospital not been available, and half would have remained at home. Eighty five per cent were discharged home, mostly in less than one month. Next, Johnson (28 April,p 1293) described surgical practice in a community hospital in Brecon. Though this hospital is atypical (in that nearly all the general practitioners have hospital specialist qualifications),he described a method ofreview which could be applied to community hospitals in general-and, implicitly, to major surgical units as well. Some 85% of all inpatient surgery on Brecon residents is performed in the community hospital; complication rates (such as wound infection and recurrence of hernia) are acceptable, and waiting lists are short. Even with anonymous questionnaires an opinion survey may be biased, but there is a clear message in the finding that of patients who had an operation in Brecon 96% said they preferred that to surgery in a district general hospital. Last week (p 1366) Grant reported on the facilities and distribution of hospitals in Scotland staffed primarily by general practitioners. Most of these are more than 30 miles (48 km) from a district general hospital and have casualty and outpatient clinics. Intrapartum maternity beds are available in almost twice as many hospitals as surgical beds. The final paper (p 1438) pursues this theme south of the border, with Cavenagh and others discussing the place of isolated general practitioner maternity units. In 131 units separate from consultant sites the "average" general practitioner has 10 deliveries a year and …