Worth a Second Look Journal of Health Services Research & Policy 2015, Vol. 20(4) 254–256 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819615585893 jhsrp.rsmjournals.com
What does a hospital mean? Lorelei Jones
Ministry of Health. A Hospital Plan for England and Wales. London, HMSO, 1962 What we know of hospitals – their location, size, the services they provide and the way they dominate the organizational landscape of the NHS, stems largely from the 1962 Hospital Plan for England and Wales. When the NHS was created in 1948 it inherited an uneven pattern of hospitals made up of a mix of voluntary and local authority provision. The aim of the Hospital Plan was to rationalize and modernize the existing hospital stock, and to better match the geographical distribution of services to apparent need. Problems identified in the Plan included obsolete buildings and a lack of investment in maintenance during Second World War. Moreover, the Emergency Medical Services hospitals built during the war were often of temporary construction and were not located with peace-time needs in mind. The intention was to use the opportunity provided by a rapid increase in capital funding to ‘take a comprehensive view of hospital needs and to formulate a long-term national plan for meeting them’.1 The Hospital Plan is often portrayed as marking the high water mark of central planning in the NHS. Following the restructuring of the NHS in 1974, responsibility for planning services was delegated to Regional Health Authorities. The hospital plan is also significant in so far as it marks the beginning of arguably the most enduring and intractable issue in the NHS, the political contest over hospital closures. The Plan itself was a collection of regional plans for hospitals based on a centrally dictated norm of 3.3 beds per 1000 population. These regional plans were published alongside an over-arching framework, the centrepiece of which was the ‘District General Hospital’. Comprising 600–800 beds and serving a population of 100,000–150,000, the Distinct General Hospital would provide, with a few exceptions, the full complement of specialist services. A smaller number of specialties that were considered to require a greater catchment area, such as neurosurgery, would only be provided at certain hospitals. The underlying assumption of the Plan was that rationalizing hospitals onto fewer sites would increase efficiency. Although the Plan anticipated that some smaller hospitals would be retained to provide a
more limited range of services, such as care for the elderly, it proposed the closure of some 700 hospitals in 10 years. According to the political scientist Rudolf Klein, the publication of the Hospital Plan reflected a nascent ‘ideology of rationality’ in national health care policy.2 At the time the Plan was published there was an increasing concern with efficiency in public spending; economists were, for the first time, recruited to key posts in the Ministry of Health; and civil servants were beginning to use techniques such as cost-benefit analysis and operational research, a legacy of Second World War military planning. The Plan also represented an alliance between the State and the medical profession. At this time, as now, the medical profession advocated the rationalization of hospitals to concentrate specialist expertise and equipment. In devising norms for the size and distribution of hospitals, the Ministry deferred to the profession. As a consequence, the Plan embodied a professional vision for maximizing the quality of medical care delivered in hospitals. This vision did not take into account other considerations, such as accessibility for patients, their families and staff who needed to travel to and from the hospital at all hours of the day and night. The rationale for the introduction of the District General Hospital was not just economic and clinical but political, reflecting an ideological commitment to the provision of a comprehensive National Health Service and to geographical equity in access to services.3 In this way, the Hospital Plan might also be seen as representing a rare convergence of economic, medical and political interests. From the outset, there was considerable community resistance to hospital closures, a situation which has
Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK Corresponding author: Lorelei Jones, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Email: [email protected]
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
Jones
255
continued to this day. The following is from a letter to the Times in 1962: The ideological centralisation proposed in the Hospital Plan is about as realistic as would be a plan to scrap all the ships in the fleet except the aircraft carriers, and about as moral as would be a plan to close all the parish churches on the grounds that the work done in them could be more efficiently organised in cathedrals.3
The correspondent is here rejecting the assumption that service efficiency should be the overriding concern in hospital planning, but there is something more. It seems to be an attempt to articulate a sense that hospitals have meaning beyond ‘capital stock’. The analogy with the parish church recognizes that hospitals have symbolic and social significance within their localities, that they are important to people’s sense of place.4 Sense of place refers to the consciousness of a locality from the insider perspective. It is based on the understanding that a place is more than the sum of its material characteristics; it can be the centre of meanings, values, significance and emotional attachment.5 In all societies, hospitals play an important symbolic role. As Glasby et al. describe, ‘hospitals are much more than just buildings where healthcare is delivered, but the physical incarnation of the NHS and its values within a particular locality’.6 The NHS was founded as part of the post-war welfare state and is symbolic of the associated values of fairness and communality. Historically, hospitals have also been a focus for local philanthropy which has created a sense of local ownership and symbolic importance as an expression of shared values. Moreover, for local communities, hospitals are a significant source of employment. This is not just of instrumental significance as places of work are important locations for socializing and identity construction.7 Hospitals are the settings of significant rites of passage, and of both physical and existential suffering.8,9 At the same time, for parents, carers, older people and those with disabilities and long-term illness, hospitals can, for a time at least, become a part of everyday life. Health care has a value and meaning to people that is fundamentally different to other publicly provided services. It is relational and intimate, and often accessed at times of fear and anxiety. And whether by individual experience, or collective imagination, hospitals exist at the juncture of life and death, and are thus intricately bound up with notions of ‘ontological security’.10 This refers to the confidence that humans have in the continuity of their self-identity and the constancy of everyday life. Giddens argues that much human activity
involves maintaining this sense of ontological security and keeping existential anxiety at bay. This anxiety stems, in part, from our realization of finitude. Thus the presence of a local hospital, with its life-saving technology, may offer a community a deep sense of reassurance. Reflecting on the multiple meanings of hospitals affords greater understanding of the difficulties managers face in convincing patients, staff and the local community of the need for change. This is not to say that change cannot or should not be sought. Indeed, looking back at local protests at the Hospital Plan, it is notable that the District General Hospital, now fiercely defended by community groups when earmarked for closure, was initially seen as remote and impersonal. What this suggests is that it is not the form that a hospital takes but the role it plays in our lives that is the source of meaning. Nor is it to suggest that a concern with efficiency is somehow unimportant or morally suspect. The problem arises when this particular concern is assumed to be a general concern, and when it comes to dominate research and policy agendas. A second look at the Hospital Plan offers an opportunity to consider what many of us value about health care and how we can incorporate this into research and policy. Looking at hospital planning today, an ideology of centralization is still apparent. For both managers and the medical profession, it is the preferred course of action, despite a range of alternatives, and despite little in the way of evidence of either financial or clinical gains.11 However, in terms of central guidance, recent statements from Simon Stevens, the chief executive of NHS England, have made it clear that he believes that the NHS is now too centralized, and that the requirements of medical training and staffing should no longer drive hospital planning. Instead, he has called for greater flexibility in responding to the particular issues of local communities.12A second look at the Hospital Plan, and the ensuing political contest over hospital closures, offers an opportunity to reflect on the wide range of issues faced by local health care managers. This complexity is not well served by abstract models of service reconfiguration that decontextualize hospitals and in so doing render them meaningless. Staff and community responses to change are not just driven by rational considerations and calculations of self-interest but also by meaning and emotion. Reflecting on the multiple meanings of hospitals can help to inspire a creative, and ultimately more acceptable, response to local circumstances. Acknowledgments The ideas in this essay were developed during many enjoyable discussions with Steve Harrison and Justin Waring.
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
256
Journal of Health Services Research & Policy 20(4)
References 1. Ministry of Health. A hospital plan for England and Wales. London: HMSO, 1962. 2. Klein R. The new politics of the NHS, 4th ed. Oxon: Radcliffe, 2001. 3. Mohan J. Planning, markets and hospitals. London: Routledge, 2002. 4. Eyles J. Senses of place. Warrington: Silverbrook, 1985. 5. Brown T. Towards an understanding of local protest: hospital closure and community resistance. Soc Cult Geogr 2003; 4: 489–504. 6. Glasby J, Smith J and Dickinson H. Creating ‘NHS local’: a new relationship between PCTs and local government. Birmingham: University of Birmingham, 2006. 7. Hughes EC. Men and their work. Toronto: CollierMacmillan, 1958.
8. Long D, Hunter C and Van der Geest S. When the field is a ward or a clinic: hospital ethnography. Anthropol Med 2008; 15: 71–78. 9. Good B. Medicine, rationality, and experience. Cambridge: Cambridge University Press, 1994. 10. Giddens A. Modernity and self-identity. Cambridge: Polity Press, 1991. 11. Jones L and Exworthy M. Framing in policy processes: a case study from local planning in the NHS in England. Soc Sci Med 2015; 124: 196–204. 12. Speech by Simon Stevens, CEO NHS England, to the NHS Confederation Annual Conference 2014. 4 June 2015. http://www.england.nhs.uk/2014/06/04/simon-stevens-speech-confed/
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
What does a hospital mean? Lorelei Jones
Ministry of Health. A Hospital Plan for England and Wales. London, HMSO, 1962 What we know of hospitals – their location, size, the services they provide and the way they dominate the organizational landscape of the NHS, stems largely from the 1962 Hospital Plan for England and Wales. When the NHS was created in 1948 it inherited an uneven pattern of hospitals made up of a mix of voluntary and local authority provision. The aim of the Hospital Plan was to rationalize and modernize the existing hospital stock, and to better match the geographical distribution of services to apparent need. Problems identified in the Plan included obsolete buildings and a lack of investment in maintenance during Second World War. Moreover, the Emergency Medical Services hospitals built during the war were often of temporary construction and were not located with peace-time needs in mind. The intention was to use the opportunity provided by a rapid increase in capital funding to ‘take a comprehensive view of hospital needs and to formulate a long-term national plan for meeting them’.1 The Hospital Plan is often portrayed as marking the high water mark of central planning in the NHS. Following the restructuring of the NHS in 1974, responsibility for planning services was delegated to Regional Health Authorities. The hospital plan is also significant in so far as it marks the beginning of arguably the most enduring and intractable issue in the NHS, the political contest over hospital closures. The Plan itself was a collection of regional plans for hospitals based on a centrally dictated norm of 3.3 beds per 1000 population. These regional plans were published alongside an over-arching framework, the centrepiece of which was the ‘District General Hospital’. Comprising 600–800 beds and serving a population of 100,000–150,000, the Distinct General Hospital would provide, with a few exceptions, the full complement of specialist services. A smaller number of specialties that were considered to require a greater catchment area, such as neurosurgery, would only be provided at certain hospitals. The underlying assumption of the Plan was that rationalizing hospitals onto fewer sites would increase efficiency. Although the Plan anticipated that some smaller hospitals would be retained to provide a
more limited range of services, such as care for the elderly, it proposed the closure of some 700 hospitals in 10 years. According to the political scientist Rudolf Klein, the publication of the Hospital Plan reflected a nascent ‘ideology of rationality’ in national health care policy.2 At the time the Plan was published there was an increasing concern with efficiency in public spending; economists were, for the first time, recruited to key posts in the Ministry of Health; and civil servants were beginning to use techniques such as cost-benefit analysis and operational research, a legacy of Second World War military planning. The Plan also represented an alliance between the State and the medical profession. At this time, as now, the medical profession advocated the rationalization of hospitals to concentrate specialist expertise and equipment. In devising norms for the size and distribution of hospitals, the Ministry deferred to the profession. As a consequence, the Plan embodied a professional vision for maximizing the quality of medical care delivered in hospitals. This vision did not take into account other considerations, such as accessibility for patients, their families and staff who needed to travel to and from the hospital at all hours of the day and night. The rationale for the introduction of the District General Hospital was not just economic and clinical but political, reflecting an ideological commitment to the provision of a comprehensive National Health Service and to geographical equity in access to services.3 In this way, the Hospital Plan might also be seen as representing a rare convergence of economic, medical and political interests. From the outset, there was considerable community resistance to hospital closures, a situation which has
Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK Corresponding author: Lorelei Jones, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Email: [email protected]
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
Jones
255
continued to this day. The following is from a letter to the Times in 1962: The ideological centralisation proposed in the Hospital Plan is about as realistic as would be a plan to scrap all the ships in the fleet except the aircraft carriers, and about as moral as would be a plan to close all the parish churches on the grounds that the work done in them could be more efficiently organised in cathedrals.3
The correspondent is here rejecting the assumption that service efficiency should be the overriding concern in hospital planning, but there is something more. It seems to be an attempt to articulate a sense that hospitals have meaning beyond ‘capital stock’. The analogy with the parish church recognizes that hospitals have symbolic and social significance within their localities, that they are important to people’s sense of place.4 Sense of place refers to the consciousness of a locality from the insider perspective. It is based on the understanding that a place is more than the sum of its material characteristics; it can be the centre of meanings, values, significance and emotional attachment.5 In all societies, hospitals play an important symbolic role. As Glasby et al. describe, ‘hospitals are much more than just buildings where healthcare is delivered, but the physical incarnation of the NHS and its values within a particular locality’.6 The NHS was founded as part of the post-war welfare state and is symbolic of the associated values of fairness and communality. Historically, hospitals have also been a focus for local philanthropy which has created a sense of local ownership and symbolic importance as an expression of shared values. Moreover, for local communities, hospitals are a significant source of employment. This is not just of instrumental significance as places of work are important locations for socializing and identity construction.7 Hospitals are the settings of significant rites of passage, and of both physical and existential suffering.8,9 At the same time, for parents, carers, older people and those with disabilities and long-term illness, hospitals can, for a time at least, become a part of everyday life. Health care has a value and meaning to people that is fundamentally different to other publicly provided services. It is relational and intimate, and often accessed at times of fear and anxiety. And whether by individual experience, or collective imagination, hospitals exist at the juncture of life and death, and are thus intricately bound up with notions of ‘ontological security’.10 This refers to the confidence that humans have in the continuity of their self-identity and the constancy of everyday life. Giddens argues that much human activity
involves maintaining this sense of ontological security and keeping existential anxiety at bay. This anxiety stems, in part, from our realization of finitude. Thus the presence of a local hospital, with its life-saving technology, may offer a community a deep sense of reassurance. Reflecting on the multiple meanings of hospitals affords greater understanding of the difficulties managers face in convincing patients, staff and the local community of the need for change. This is not to say that change cannot or should not be sought. Indeed, looking back at local protests at the Hospital Plan, it is notable that the District General Hospital, now fiercely defended by community groups when earmarked for closure, was initially seen as remote and impersonal. What this suggests is that it is not the form that a hospital takes but the role it plays in our lives that is the source of meaning. Nor is it to suggest that a concern with efficiency is somehow unimportant or morally suspect. The problem arises when this particular concern is assumed to be a general concern, and when it comes to dominate research and policy agendas. A second look at the Hospital Plan offers an opportunity to consider what many of us value about health care and how we can incorporate this into research and policy. Looking at hospital planning today, an ideology of centralization is still apparent. For both managers and the medical profession, it is the preferred course of action, despite a range of alternatives, and despite little in the way of evidence of either financial or clinical gains.11 However, in terms of central guidance, recent statements from Simon Stevens, the chief executive of NHS England, have made it clear that he believes that the NHS is now too centralized, and that the requirements of medical training and staffing should no longer drive hospital planning. Instead, he has called for greater flexibility in responding to the particular issues of local communities.12A second look at the Hospital Plan, and the ensuing political contest over hospital closures, offers an opportunity to reflect on the wide range of issues faced by local health care managers. This complexity is not well served by abstract models of service reconfiguration that decontextualize hospitals and in so doing render them meaningless. Staff and community responses to change are not just driven by rational considerations and calculations of self-interest but also by meaning and emotion. Reflecting on the multiple meanings of hospitals can help to inspire a creative, and ultimately more acceptable, response to local circumstances. Acknowledgments The ideas in this essay were developed during many enjoyable discussions with Steve Harrison and Justin Waring.
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
256
Journal of Health Services Research & Policy 20(4)
References 1. Ministry of Health. A hospital plan for England and Wales. London: HMSO, 1962. 2. Klein R. The new politics of the NHS, 4th ed. Oxon: Radcliffe, 2001. 3. Mohan J. Planning, markets and hospitals. London: Routledge, 2002. 4. Eyles J. Senses of place. Warrington: Silverbrook, 1985. 5. Brown T. Towards an understanding of local protest: hospital closure and community resistance. Soc Cult Geogr 2003; 4: 489–504. 6. Glasby J, Smith J and Dickinson H. Creating ‘NHS local’: a new relationship between PCTs and local government. Birmingham: University of Birmingham, 2006. 7. Hughes EC. Men and their work. Toronto: CollierMacmillan, 1958.
8. Long D, Hunter C and Van der Geest S. When the field is a ward or a clinic: hospital ethnography. Anthropol Med 2008; 15: 71–78. 9. Good B. Medicine, rationality, and experience. Cambridge: Cambridge University Press, 1994. 10. Giddens A. Modernity and self-identity. Cambridge: Polity Press, 1991. 11. Jones L and Exworthy M. Framing in policy processes: a case study from local planning in the NHS in England. Soc Sci Med 2015; 124: 196–204. 12. Speech by Simon Stevens, CEO NHS England, to the NHS Confederation Annual Conference 2014. 4 June 2015. http://www.england.nhs.uk/2014/06/04/simon-stevens-speech-confed/
Downloaded from hsr.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
