The general practitioner and the hospital.

1OR the last 18 years I have been closely associated with a cottage hospital and i general-practitioner maternity unit. The interest they give to the family doctor and the confidence he can instil into his own patients mast not be lost sight of in the changing pattern of practice. The closed door of the district and teaching hospital to all who are not on the consultant staff is a tragedy of the growth of the Health Service. This dichotomy between hospital and community practice has deep-seated roots in their different disciplines and methods. We must not underestimate these since they produce professional tension and sometimes antagonisms and may become more marked as technological complexity increases-the stronghold ofthe consultant cannot be stormed by the mass of general practitioners, we must have a plan of integration that will be to the benefit of patient, consultant and general practitioner, and we shall have to work hard to have this plan accepted and even harder to make it work. In Britain, to quote the Report and Recommendations of a Ministry of Health Interview Board on discussion in N. America with British Trained Doctors (1968), the National Health Service has inspired "an incisive separation . . . between hospital and general practice." This is not a plea to return to the 'good old days'-but'rather an attempt to put in perspective the various possibilities for a better continuity of care of the patient and a closer relationship between general practitioner and hospital practice. The cottage hospitals have strong local support and tap the part-time staff in areas which would often be denied to the larger units. They are criticjzed and closed for the following reasons: (1) that they are uneconomic, and that (2) they function in professional isolation without full or up-to-date diagnostic aids, thus offering -a second-class service. I am aware that certain of these hospitals are costly because bed occupancy is low, but this often reflects the consultant attitude, the consultant in his wisdom, often seeing a patient at the request ofthe general practitioner, will transfer him to a district hospital, not necessarily for further diagnostic procedures-these can often be covered by the parent hospital, even at a distance, but to halve the responsibility and bring the house officer in as the doctor with initial responsibility. This attitude is born of misunderstanding and can be overcome by closer general-practitioner-specialist co-operation. Such hospitals need not be uneconomic compared to the larger unit as experience in New Zealand shows. Bed occupancy and maintenance costs by size of institution in that country show that although the unit of less than 50 beds has an occupancy rate of 70.5 per cent compared with about 85 per cent in the larger unit, the corrected cost per actual bed is about the same (Hospital Statistics of New Zealand (1964) Wellington). These cottage hospitals and general-practitioner maternity units offer the easiest method of integration where the general practitioner can exercise his skills with clinical freedom, and where the patient finds the benefit ofa personal physician who cares for the *Read during a postgraduate course in Southampton on 3 November 1968.