7—
Historical Development of Health Care Services

The problems of the elderly in Britain and the United States are similar; nevertheless, there are major differences in the approach to the care of the disabled elderly in the two countries.

Although the historical development of medical care in the two countries may be of interest and clearly does have some relevance in current governmental policy toward the care of the aged, it is a complex subject that lies without the scope of this book. I will make no attempt, therefore, to present a detailed picture of this historical development. Rather, because the structure of a medical care system is related to the social, economic, and ethical values of the society of which it is a part, I will briefly discuss the social conditions responsible for the development of public health policy and subsequent governmental programs for personal health care in each country. Additionally, some comparison will be made in an attempt to explain the differences in the present-day approach to the care of the aged.

Although the United States and Great Britain possess a common language, and the first American physicians were trained in Britain, our health care systems have developed in strikingly different ways. In Great Britain a welfare state has evolved, and within it, the National Health Service is the organ by which medical care is provided. The National Health Service, which came into being on 5 July 1948, pays for virtually the

entire range of health and medical care without regard to age, income, need, or insurance qualification.

In the United States medical care is financed publicly by the federal, state, and local government and privately by health insurance companies and direct payments by patients to physicians on a fee-for-service basis. In the past the private share has always been by far the largest, but in recent years, because of the Medicare and Medicaid programs, there has been a shift to more public financing. With the 1965 enactment of Medicare for the aged and Medicaid for the poor, the government established the first major federally financed program that provides hospital and medical insurance protection both for people 65 years of age and older and for the indigent.

Historical Development of Health Care Services in Britain

Britain has a long social history, and provision of medical care and social services has evolved and adapted through changing sociological systems over the past 300 years. In the Middle Ages the benevolent landlord was responsible, if he so wished, for providing medical services for his tenants and servants; he also provided for his people in their infirmity, disability, and old age.

Infirmary almshouses and Houses of Pity for the destitute, sick, and aged were run largely by the monasteries. The medieval church took a positive approach to human distress by emphasizing that the relief of distress was as important for the giver as for the person in need. This doctrine lent dignity to poverty and made the granting of alms a meritorious deed. In the sixteenth century, Henry VIII expropriated the monasteries and turned over their properties to his followers. After this transition, hospitals became secular institutions and charitable bodies maintained the majority of hospitals for acute care. Voluntary hospitals began to be established in all parts of the country during the eighteenth century; and in the nineteenth century, there was a rapid growth of the voluntary hospital movement (Stevens 1966:14).

In the nineteenth century, personal health care was primarily regarded as the responsibility of the individual. The Poor Laws did make some provision for the care of the indigent who were ill; infirmaries were usually

attached to the workhouses. Other groups organized among the poorer people to provide some sort of prepayment insurance; and by the end of the nineteenth century, there were large Friendly Societies providing, under contract, some type of medical care as well as payments during illness (U.S. Department of Health, Education and Welfare 1976).

In the same era concern for the environment arose. By the middle of the nineteenth century, government began to concern itself with improving sanitation, particularly in the cities, a concern brought about by the movement of masses of people during the Industrial Revolution. With the Industrial Revolution of the eighteenth and nineteenth centuries, England was among the first countries to be faced with urban slums, open sewers, and contaminated water supplies. From 1801 to 1851 the population of England grew from 8,892,000 to 17,927,000 (Brand 1965). Urban industrial life created major medical and social problems as cholera epidemics swept through England in 1831, 1848, and 1853. Chadwick's study (1842), "Report of an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain," described the sanitary ills of the nation and provided the impetus for much of the public health legislation that followed. This report led to the passing of the Public Health Act of 1848 (Brand 1965:3). The "sanitary idea," or Chadwick's principle—that improvement in the material environment would advance the physical well-being of the English people—was of far more importance to mid-nineteenth-century sanitation reformers than the improvement of public medical care (Brand 1965:3). Public measures to promote healthier living conditions, it seems, preceded adequate public provision for the care of the sick.

The extension of public medicine was a social rather than a scientific phenomenon and stemmed largely from the public health legislation of the late nineteenth and early twentieth centuries (Stevens 1966:36). Public health systems had been introduced throughout Europe; and following Bismarck's example in Germany, David Lloyd George, Chancellor of the Exchequer, introduced the National Health Insurance Act in 1911. This legislation provided a method whereby all people earning wages of less than £ 160 a year were entitled to the services of a general practitioner in return for their own regular contributions and those of their employers to certain insurance organizations known as approved societies; no provision was made for their dependents. The National Insurance Act of 1911 provided free medical care by general practitioners but not by hospitals or

specialists (Stevens 1966:36). These services provided some care for the poorer half of the population, whereas the other half of the population had either to pay fees as private patients or depend upon voluntary sick clubs for medical care.

These various health services were seen to be inadequate, and proposals for full health and medical services were the subject of many reports in the years between World War I and World War II. It was the Second World War, however, that precipitated a major reform in health care services. All levels of English society at this time were united as never before in their agonizing struggle for survival. For the first time many physicians became aware of the need for reform. To deal with the war wounded, the Emergency Hospital Service utilized both voluntary and municipal hospitals for treatment and hospitalization of war casualties. In effect, Britain established in 1939 what was virtually a national hospital service to meet the needs of the war; moreover, it was because of this act that many of the leading physicians from prestigious teaching hospitals, involved in this war-time care, saw for the first time the poor conditions in many of the hospitals run by local authorities as well as in some of the voluntary hospitals (Abel-Smith 1972). Both the medical profession and the government agreed, in the early years of the war, on the need for reform of civilian health services. There was some disagreement about details regarding organization of such a service, but the principle of establishing a national health service was never an issue among Great Britain's political parties. In 1941 a committee was set up under Sir William Beveridge to survey the existing national schemes of social insurance and make recommendations as to the reconstruction of social services after the war. The committee's report, Social Insurance and Allied Services: Report by Sir William Beveridge , known as the "Beveridge Report," was published in 1942. The Beveridge Report recommended many changes that involved considerable extension of health and social services and formed the basis for much post-war social legislation.

In 1943 the government announced its acceptance of the proposal in the Beveridge report: that a comprehensive health service for all purposes and all people should be established under the supervision of the Health Department (Social Insurance and Allied Services: Report by Sir William Beveridge 1942–48). The 1945 election put a Labour government into power and Aneurin Bevan into the Ministry of Health, a combination that assured the acceptance of, first, a free health service for the entire popula-

tion regardless of income and, second, the nationalization of the hospitals. The final plan was embodied in the National Health Service Act of 1946, and it began to operate on 5 July 1948.

The purpose of the National Health Service (NHS) is (1) to provide a system of medical services directed towards the achievement of positive health, the prevention of disease, and the relief of sickness, and (2) to render available to every individual all necessary services, both general and specialist, both domiciliary and institutional (Murray 1974:30). When introduced, the NHS was an immediate success in that almost everyone used the service and the great majority of doctors chose to participate in the system. Today only a small minority of specialists, about 2 percent of general practitioners and a negligible number of dentists, pharmacists, and opticians, take no part whatsoever in the NHS.

The National Health Service

Some of the important concepts of the structure of the health service are:

1. Financing. The National Health Service is financed from the following sources: 88 percent of the funds are derived from general taxation (Exchequer funds), 9 percent from NHS weekly contributions, 2.5 percent from co-payment by patients for certain services such as drugs, eyeglasses, and so on, and 0.5 percent from miscellaneous sources.

2. Benefits. The NHS pays for virtually the entire range of health and medical care, and care is free to the patient at the time of service without regard to age, income, need, or insurance qualification.

3. Practitioner Service. This service includes the family doctor service (general practitioner), the dental service, the ophthalmic service, and the pharmaceutical service. Patients register with a general practitioner and receive most primary services through him. Patients have a free choice of physician and are free to change doctors if they so desire. The practitioner is also free to accept or reject a particular patient. Throughout Britain, 97 percent of the population is registered with a family doctor. There are

some small charges made for dentures, eyeglasses, and patients usually pay a charge of 20 pence (35¢) for each prescription item. Certain groups of people such as children under 16, expectant mothers, men aged 65 and over, and women 60 years of age and over are exempt from these charges.

4. Hospital Services. All forms of hospital care and treatment are provided free of charge by the NHS. As a rule, patients are referred by their family doctors, who make arrangements with a specialist for their treatment and care in the hospital. In general, the family doctor does not have hospital privileges, but he may visit the patient in the hospital. All hospital services such as X-ray, laboratory, and rehabilitation services (physical therapy, speech therapy, and occupational therapy) are available free of charge to the patient.

5. Community Health Services. The care of patients in the community has been emphasized in Britain, and community services are well developed. The NHS provides a wide variety of community services, including maternity and child health services (family planning, midwifery, and baby care), home nursing, health visitors, vaccination and immunization, ambulance services, and health education for the public. During the past 26 years, there has been considerable progress in the development of health centers staffed by general practitioners, dentists, district nurses, and health visitors (registered nurses) to provide services for the prevention of illness as well as for general medical, dental, and pharmaceutical services. The traditional role of the health visitor centered on mothers and young children; however, increasingly she has been utilized in the care of old people in the community (Brocklehurst 1975).

6. Payment for Services to Health Personnel. Hospital doctors and personnel are salaried employees. Their salaries are set by the government and are standard throughout the country. Hospital consultants (specialists) may be part-time or

full-time; part-time staff are usually remunerated at a proportion of a full-time salary and are free to accept private patients. Senior hospital consultants earn salaries ranging from £ 7,500 to £ 10,700 a year (about $17,600 to $25,000 United States currency, as of December 1975). A general practitioner is paid a capitation fee for each patient on his patient list. A physician may maintain a list of up to 3,500 patients, but the size of the average practice is 2,400 patients. As of October 1966, a special payment has been made to general practitioners for every person aged 65 and over on their practice lists. Additional payments are made for practicing in doctor-shortage areas, for accepting responsibility for patient care out of normal hours, for night visits to patients in their homes, and for expenses associated with a rural practice. The British Medical Association estimated that as of April 1973 the average net income of the general practitioner was $14,300 annually and the average net income for top specialists was $19,000 (Committee on Ways and Means 1976).

Geriatric Care in Britain

The National Health Service Act of 1946 made it possible to promote geriatrics as a new specialty in medicine (Brocklehurst 1975). Geriatric medicine is concerned with the clinical, social, preventive, and remedial aspects of illness and the maintenance of health in the elderly (Anderson 1976). Although the NHS provided a structure for the organization and financing of geriatrics, progress in the care of the aged really began in the late 1930s, before the establishment of the NHS.

During the nineteenth century and extending into the early part of the twentieth century, many aged, because they were poor, received health care through the Poor Law hospital system. Many of the workhouses had adjoining hospitals or infirmaries, and in 1906 45 percent of the workhouse inmates were 60 years of age and over (Townsend 1962). Under the Local Government Act, 1929, the Poor Law infirmaries gradually began to be appropriated by health departments of the local governments, which were already responsible for the mental hospitals, infectious disease hospitals, and tuberculosis sanatoria (Stevens 1966:59). It was in these beds that

the emerging specialty of geriatric medicine began to develop in the late 1930s.

The person who is generally regarded by British geriatricians as the pioneer in geriatric medicine is the late Dr. Marjorie Warren. In 1935 Dr. Warren was given the task of reorganizing the treatment of several hundreds of aged, chronic sick at the West Middlesex Hospital in London. The hospital had taken over the adjacent Poor Law infirmary that housed hundreds of old people along with children and healthy and infirm patients. Dr. Warren, described by those who knew her as an exceptional woman totally ahead of her time, realized the infirmary contained large numbers of patients who were inadequately diagnosed and improperly treated. Conditions in such infirmaries, which have since been termed "human warehouses," were dreary and depressing, and the patients' morale was very low. Most had lost hope of ever recovering. Dr. Warren began by classifying patients under her care: the ambulant were sent to welfare hotels, the ill were grouped together and given thorough medical treatment, the infirm were encouraged to be more active, and the frail were studied to determine the cause of their weakness. Dr. Warren attended not only to their physical needs, but their mental and social needs as well. Wards were redecorated in light, bright colors, and new furnishings made the rooms look clean and cheerful. Subsequently, patients became happier and began to have hope for recovery. People who had been categorized as chronically ill began to improve and return to reasonable health and activity, fewer and fewer beds were needed, and Dr. Warren began to develop a special geriatric unit with about one-third of the beds she originally had taken over (Howell 1963). Her unit became a model for geriatric care, and visitors came from throughout the country to observe and learn so that they might develop similar facilities. Many physicians were influenced by the enthusiasm and common-sense approach of Dr. Warren. Today geriatrics is a recognized specialty in Britain.

Many medical schools include the teaching of geriatric medicine in their medical school curriculum; the University of Glasgow has been teaching geriatric medicine in the school of medicine for the past 25 years. British geriatricians believe there is a sufficient body of knowledge within the specialty of geriatrics to make it a worthwhile subject and that emphasis should be given to the subject in the teaching of medical students at all stages in their training. A Chair in Geriatric Medicine has been created in universities in Belfast, Birmingham, Edinburgh, Glasgow,

London, Manchester, and Southampton; and this has greatly encouraged the development of teaching in geriatric medicine (Personal Interview Professor Sir Ferguson Anderson 1977).

Community Services

The philosophy of geriatric care in Britain is that old people should be kept in their own homes and as independent as possible for as long as it is feasible.^[1] This has been possible because of the extensive development of community and social services since the inception of the NHS. The domiciliary services include: home helpers (domestic assistants who aid the aged with household tasks such as shopping, cooking, and cleaning), meals-on-wheels, home nursing service, volunteer friendly visitors, podiatry services in the home, home physiotherapy, and occupational therapy (Anderson 1976).

Community services also include various levels of housing accommodations for the elderly who are unable to remain in their own homes. These facilities are provided by the local government or voluntary agencies; proprietary or commercial interests are not involved.

Sheltered housing has proved a most satisfactory solution for old people who wish to maintain some degree of independence but also need some supervision and attendance. In this type of living arrangement, the elderly reside in small, apartment-type units that allow them to have their own furniture and belongings and to organize their lives as they wish. A matron (often a registered nurse) lives in the complex, makes daily rounds to visit all of the residents, and is always available through a call system should the aged resident need help.

Residential homes are available for those who are more dependent, that is, for those who are unable to prepare their own meals and carry out certain aspects of their personal care. To qualify for residential care, prospective residents should be able to walk, feed, and dress themselves without assistance; and they should be continent of urine and feces. Residential homes are primarily staffed with domestic help only; if nursing care is needed the person should be transferred to an appropriate medical facility. However, while visiting a residential home or a sheltered housing project, the matron would periodically single out an elderly resident who

[1] Although institutional care is the primary focus of this study, a brief discussion of community services is necessary for a broad understanding of geriatric care in Britain.

"should be transferred" because she could no longer care for herself, but, in fact had not been transferred because the matron knew the patient was very attached to the home. She felt the move would be harmful to the resident. The matrons I met in these homes were, without exception, dedicated and one might even say devoted to the elderly residents. The aged were obviously very fond of them, and the matrons cared very much for their elderly residents.

The Geriatric Day Hospital

The geriatric day hospital is another service for the aged in Britain that helps keep old people in the community; it prevents unnecessary hospital admissions, and in some cases it allows the patient to be discharged from the hospital at an earlier date. The first purpose-built^[2] geriatric day hospital opened in Oxford in 1958, and by 1970 there were 120 established day hospitals in Great Britain and Northern Ireland (Brocklehurst 1970). The day hospital is open five days a week, and patients are brought into the hospital by an ambulance provided by the National Health Service.

Day hospitals must be differentiated from day centers. Day centers are usually run by the local authority, by voluntary groups, or by both, and they primarily provide social and recreational activities and a hot cooked meal at midday. The geriatric day hospital has a therapeutic focus, providing rehabilitation care (physical therapy, occupational therapy, and speech therapy), maintenance treatment, and medical and nursing care. Patients who have been seen in the home by a geriatrician may come into the day hospital for further examination or for X-rays and laboratory tests. Geriatricians have found that frequently an elderly patient, who may be reluctant to leave his home and be admitted to the hospital as an in-patient, will agree to come to the day hospital for out-patient diagnosis, treatment, and rehabilitation. It is also more economical to care for the elderly on an out-patient basis.

Although the day hospital is primarily therapeutic, social aspects of care are also taken into consideration. Patients arrive at the facility between 8 A.M. and 10 A.M. and are immediately served tea and biscuits. There is a beauty salon in the hospital; some of the women may have a shampoo and hairset while waiting to see the geriatrician. At lunchtime

[2] "Purpose built" is a British expression that is roughly equivalent to our "built for the sole purpose of. . . ."

they are served a hot meal, and at 2 P.M. tea and biscuits are served before they return home. Patients with physical disabilities may be brought to the day hospital for purely social reasons. A physical disability may isolate an elderly person in the community, and perhaps because of this disability, he cannot utilize the day center. The opportunity to join other elderly people in a pleasant social environment is beneficial to a person who may have few, if any, other social contacts.

The geriatric day hospital is a very successful, progressive concept in the care of the aged patient. Many elderly people have multiple chronic illnesses that require maintenance treatment and rehabilitation. If this care is not provided, the aged person's condition will frequently deteriorate to a point where institutionalization in an acute or continuing care unit becomes necessary. The geriatric day hospital is another means of keeping the aged person independent and in his home for as long as possible.

The Geriatric Service

Completing the spectrum of care for older people in Britain, the geriatric service, using Dr. Warren's pioneering work as a model, has been organized throughout the country in the past 25–30 years. The geriatric service comprises three types of wards: assessment, rehabilitation, and continuing care. When an old person becomes ill, either in his own home or in special housing, the general practitioner is called. General practitioners make home visits when necessary and determine if the patient needs to be seen by a geriatrician. If so, in most circumstances the elderly person is assessed at home by the geriatrician. A junior member of the medical house staff occasionally makes the assessment visit, but this initial contact is considered so important that most geriatricians do not delegate it to others. Most geriatricians agree that the patient is best assessed at home; thus, an evaluation of the family and home conditions, as well as a clinical medical assessment, can be made at the same time. This home visit gives the consulting geriatrician a complete picture of the aged person in a natural setting, and it is helpful later on in making discharge plans. It is also of great value in developing rapport between the old person and the new doctor, the hospital consultant. Another reason for making a home assessment visit is that the demand for geriatric beds usually exceeds the available supply; thus, the consultant responsible for the patients can establish priorities for admission to the geriatric unit. If it is necessary to have a further diagnostic examination/treatment following the home visit, the person is admitted to the geriatric unit.

In her early work, Dr. Warren strongly advocated that geriatric units be an integral part of the general hospital, that they not be divorced from the mainstream of medicine. In providing care for the geriatric patient, therefore, geriatricians not only have access to all hospital services, such as X-ray, laboratory, and physiotherapy, they also have immediate access to consultants in other specialties. If necessary, patients can easily be transferred to another unit for treatment and care. For example, in one instance the geriatrician had been asked to see an elderly woman who was referred as a "social problem" because she was no longer able to walk. She was admitted to the geriatric unit and upon examination was found to have a tumor on her spine. The patient was immediately transferred to a surgical unit, surgery was performed, and following rehabilitation, the patient could walk again and returned to her home.

Assessment Ward

The assessment ward (also called the acute geriatric unit) receives patients from their own homes or from community residential facilities. Of those admitted to the assessment ward, 46 percent return to their own home, 36 percent are discharged to rehabilitation or continuing care units, and 18 percent die (Brocklehurst 1975). The average length of stay on the assessment ward is two to three weeks, and the emphasis is on diagnosis and treatment. Social workers assist in the investigation of the patient's social problems and help in the assessment planning of the patient's future. It is impressive to observe the number of people who function as a team in the geriatric unit. The team consists of the geriatrician, supporting medical staff, nurses, physiotherapists, occupational therapists, diversional therapists, chiropodists, speech therapists, social workers, community liaison nurses, and secretarial staff. There is a strong spirit of cooperation and interdependence, and geriatricians acknowledge that a "team effort" is not only desirable but necessary for them to plan and carry out the best possible treatment and long-term goals for the elderly patient.

Rehabilitation Ward

The rehabilitation ward receives most of its patients from the acute geriatric ward, but some patients are also admitted from medical, surgical, and orthopedic units. Treatment in the rehabilitation ward, again, is very much a team effort; the emphasis throughout is on physical, social, and mental rehabilitation. The average length of stay on the rehabilitation

ward is two to three months. Approximately 57 percent return to their own home or an old people's home, 27 percent are transferred to a continuing care unit, and 16 percent die (Brocklehurst 1975).

Continuing Care Ward

If after a period of time on the rehabilitation ward, it becomes apparent that the patient is not going to achieve the necessary physical or mental independence to return home, he is admitted to a continuing care unit. These units were previously called "long-term units," and some health care professionals continue to use this term; however, recently an attempt has been made to change the terminology to "continuing care." There is concern that the elderly and their family will feel abandoned by the professional health care team, and it is felt the term "continuing care" will convey to the patient and the family that everything possible is being done to keep the aged patient as healthy, normal, and independent as possible. The majority of the patients who are admitted to the continuing care ward remain there until their death; this ward becomes their final home.

The preceding pages have presented an overview of the ideal structure of the geriatric service in Britain. While one geriatric department may differ from another in minor ways, this common pattern of progressive care is found in most areas. Although British geriatric medicine has made great progress since the 1940s and British Geriatric Care is considered among the finest in the world, development of the service has been uneven throughout the country. The geriatric service is not without its problems. For example, there is a shortage of British-trained geriatricians as well as a shortage of appropriate beds and facilities for the aged. The provision of comprehensive geriatric care in the community still remains problematic in some areas.

Despite the tremendous growth in the number of geriatricians, from four or five in 1948 to more than three hundred at the present, recruitment of physicians to the specialty of geriatrics remains a problem. Geriatrics is still seen as a low-status specialty, and this stigma contributes to a shortage of British-trained geriatricians. Many consultant appointments in geriatric medicine are filled with graduates of foreign medical schools (Brocklehurst 1975:34), yet in England and Wales in 1975, 10 percent of the geriatric consultant posts were unfilled (Report of the Working Party of the Royal College of Physicians of London 1979).

A shortage of facilities at all levels of care (residential homes, sheltered housing, continuing care hospitals, and beds in acute hospitals and in geriatric units) contributes to a host of problems. Many patients are discharged to their homes because there is no available space in residential homes, yet they must leave the hospital to make room for the more acutely ill elderly waiting to come in (Brocklehurst 1978). Complaints are frequently made that elderly patients are blocking beds in acute medical and surgical wards. Rubin and Davies (1975) found the reason elderly patients were remaining longer than necessary in acute wards was the length of waiting lists for alternative residential housing.

The lack of appropriate accommodations also contributes, in part, to misplacement of the elderly. Carstairs and Morrison (1971), for instance, studied all of the homes for the aged in Scotland and found that, of the total group of 10,906 residents, 61.4 percent would be more appropriately placed in sheltered housing, 15.3 percent were considered more properly placed in residential homes, 11 percent would be more suitably placed in a home for the mentally infirm, and 11.9 percent belonged in a hospital.

Adequate provision of medical care following hospitalization has also been identified as a problem. The failure of the family practitioner to provide follow-up care is well documented. Brocklehurst and Shergold (1969) found that 47 percent of the patients discharged from two geriatric units had no contact with their general practitioner during the first month after leaving the hospital. This immediate post-hospital period is considered critical in the patient's care.

There are other problems in the care of the elderly in the community. Williamson et al. (1964) have drawn attention to a considerable amount of undiagnosed physical illness in elderly persons in the community. Similarly, there is a high incidence of unrecognized mental illness among the elderly, both in the hospital and in the community (Bergman et al. 1965; Bergman and Eastham 1974). Underlying many of these problems is a shortage of financial resources. Many of the buildings occupied by the elderly are old and unsuitable; the majority were built in the nineteenth century (Brocklehurst 1975). Financial resources are also necessary to provide additional community services for those elderly who, with supportive care, could remain in their homes. Yet despite these deficiencies, the progressive and innovative concept of British geriatric care provides an interesting model for comparison with long-term geriatric care in the United States.

Historical Development of Health Care Services in the United States

The development of medical care in the United States, although more recent than that in Britain, is also more varied and difficult to characterize. The roots of American medicine can be traced to England and the Continent. American medicine relied heavily on the scientific leadership of England and Scotland until about 1820; then France, and finally, after the Civil War, German universities provided American doctors with training that enabled them to establish research centers at medical schools in the United States (Stevens 1971:55).

Among the early practitioners who came to the colonies were a small number of physicians holding university degrees, but for the most part the colonial physicians had no formal training; more commonly, they were ships' surgeons and others who became doctors through apprentice training (Shryock 1960:7). These beginning practitioners took on apprentices of their own and thus apprenticeship became the chief mode of education for physicians. In a colonial world dominated by fevers, infections, malnutrition, and very high mortality rates, New England ministers and southern planters acted as both lawyers and physicians, and schoolmasters and other educated men were forced, out of necessity, to dispense medical advice (Stevens 1966:12). All of these practitioners were termed "doctors," but in fact they resembled the surgeon-apothecaries of rural Britain.

The absence of a metropolitan or university focus in the colonies, the prevalence of "domestic" medicine, and the training of physicians through apprenticeship discouraged the stratification that occurred between the university-trained physicians and the nonuniversity-trained surgeons and apothecaries in Britain. The categories of physicians, surgeons, and apothecaries that existed in England until the nineteenth century never developed in the United States. The apprenticeship system encouraged the development of an all-around bedside practitioner who practiced medicine, surgery, midwifery, and also dispensed his own drugs. Indeed, for many physicians the dispensing of drugs became necessary for financial survival (Stevens 1966:14).

In summing up medicine in early colonial America, one can say that disease conditions were more serious than in Europe, that inadequate as European medical science was, it reached the colonies only to a limited degree. During this time medical care was largely ignored by both the

church and state, and voluntary services reflected an unplanned adaptation of British tradition to the American situation (Shryock 1966:7).

In the United States in the seventeenth, eighteenth, and nineteenth centuries, medicine as a profession developed slowly. In Paris between 1750 and 1850, hospitals began to be used for research, thus forming a center for the development of medical science; in Britain, hospital expansion also began before 1850. In the United States, however, there was no widespread development of hospitals before the 1880s, nor was there a strong professional medical organization to initiate reform (Stevens 1966:10).

Rapid urbanization and immigration brought about the further development of hospitals in the major cities in the late nineteenth century; at the same time, these same two factors created slums that contributed to massive outbreaks of infectious disease. Thousands of impoverished immigrants poured into the seaboard cities of New York and Boston, where the inadequate provision of housing, water supplies, sewage disposal, and drainage produced an urban environment similar to the slums in London and other English cities. During the nineteenth century, there were repeated epidemics of cholera and yellow fever, and at the same time other infectious diseases such as smallpox, typhus, typhoid, dysentery, diphtheria and scarlet fever were causing high mortality rates.

Chadwick's 1842 Report profoundly affected Americans who were concerned with public health conditions; clearly, Lemuel Shattuck's Report of the Massachusetts Sanitary Commission (1850) drew heavily upon the work of Chadwick. But whereas Chadwick's report led to the passage of the Public Health Act of 1848 in England, in the United States the Shattuck Report had practically no immediate effect. One of its major recommendations—that a state board of health be established to deal with the urban health conditions—was not implemented until 19 years later. Shattuck also recommended the establishment of a state health department and local boards of health in each Massachusetts town. He stressed the need for smallpox vaccination and advocated well-child care and school health and mental health programs. The farsightedness of this report is illustrated by Shattuck's proposals on smoke control, alcoholism, town planning, and the teaching of preventive medicine in medical schools. Although a farsighted man, Shattuck was limited by contemporary political and social trends; he died in 1859 after unsuccessful attempts to have the Report enacted into law (Rosen 1958:240–43).

The lack of government involvement in matters of public health in the

United States contrasts sharply with the government's involvement in Great Britain. Whereas in Britain there was national responsibility for public health in the latter part of the nineteenth century, in the United States the federal government took little action in public health matters. Community health was considered the responsibility of state and local governments. Throughout the nineteenth century, the only involvement of the U.S. government in public health functions was that carried out by the Marine Hospital Service (founded in 1798) to care for sick and disabled seamen (Brand 1965:237). The American political philosophy, with its emphasis on states' rights, delayed any national action for public health until it became clear that state and local governments were unable to handle many health and welfare problems. In 1878 a severe outbreak of yellow fever in the Mississippi Valley, causing great loss of life, brought forth a public demand for action. In the following year Congress created a temporary National Board of Health responsible to the President. This agency was so unpopular that four years later, in 1883, Congress, imbued with the concept of states' rights, failed to pass a reenactment bill. Incredible as it seems, not until 1953, 70 years after the demise of the National Board of Health, was an independent, national health agency established in the United States. The Marine Hospital Service (renamed by Congress in 1902 the Public Health and Marine Hospital Service, and 10 years later again renamed the United States Public Health Service) was based in the Treasury Department until 11 April 1953, when it was transferred to the newly created Department of Health, Education, and Welfare (Rosen 1958:469).

The reluctance of the federal government to become involved in public health matters can also be seen in the lack of government action in personal health care in the United States. In the early part of the twentieth century, a number of organizations studied the development of social security plans that covered the working population for accident insurance, old-age pensions, sickness insurance, and health benefits. With the encouragement of President Theodore Roosevelt, the first federal workmen's compensation act was passed in 1908 for civil employees; between 1910 and 1915 workmen's compensation laws were passed in thirty states. Health insurance was considered the next logical step; under the leadership of the American Association for Labor Legislation and with the support of the American Medical Association (AMA), a standard health insurance bill was introduced in fifteen states in 1917. But no health

insurance act became law. In the meantime, opposition to compulsory health insurance had rallied within the medical profession, commercial insurance companies, and other groups. The governmental role in compulsory health insurance was seen as undesirable paternalism, and compulsory health insurance was attacked as being socialistic, tyrannical, "un-American," and "German" (Stevens 1966:138).

Following World War I, at a time when compulsory health insurance was commonplace in Europe, the AMA increasingly opposed government health insurance. In the Sheppard-Towner Act of 1921, the AMA faced yet another governmental action in health care; this act authorized federal money to states for the improvement of the health of mothers and children. The AMA opposed this act in 1921 and its renewal in 1926. The Association said the act threatened states' rights and endangered the fabric of the American home; under increasing opposition from the AMA, attempts to renew the act in 1931 and 1932 were unsuccessful. It was not until the Social Security Act of 1935 that federal-state programs for maternal-child health were reborn.

During the Great Depression many people were unable to pay their medical bills; hospitals were in serious financial trouble and many closed. The Hill-Burton Act of 1946, which provided funds for hospital construction and modernization of hospitals, was the most important piece of health legislation in the post-war period (Stevens 1966:269). Still, any proposal of a truly national health insurance had little chance of being endorsed by the AMA. Rather, the AMA endorsed hospital insurance (Blue Cross) and committed itself to private health insurance.

By 1967, 76.6 percent of the civilian population had some form of private insurance coverage. Voluntary health insurance (as opposed to compulsory or government health insurance) combined with private, fee-for-service practice, became the dominant characteristic of financing personal health in the United States. Voluntary insurance grew rapidly after World War II as health insurance became a part of fringe benefits, and fringe benefits acquired a new importance in the collective bargaining of labor unions. Millions of workers in the steel and auto industries received health insurance coverage in this way; moreover, the medical association used this enormous growth of voluntary health insurance to argue against a national health insurance plan. Numerous bills for national health insurance died in Congress in the 1940s. In 1945 President Truman took a strong position in advocating national health insurance; the legislation he

proposed would have produced a compulsory, comprehensive national health insurance system. The AMA labelled the bill as "regimentation" and "totalitarianism," and Senator Robert Taft called it "the most socialistic measure that this Congress has ever had before it": the bill did not pass (Stevens 1966:272).

It was not until 1965, with the enactment of Medicare (for the aged) and Medicaid (for the poor), that the federal government assumed a major role in the financing of health care in the United States. Earlier, federal health activities had been limited to traditional public health functions; the support of medical research; and the provision of medical care for the military, for veterans, and for merchant seamen who were cared for in Public Health Service hospitals. With the financing of Medicare and Medicaid, the federal expenditure for health care has increased dramatically. Before these two programs went into effect in 1965, annual federal expenditures in health were about $4.4 billion; in 1970 the total was $18 billion, and current figures show that "indirect" health services, in which Medicare and Medicaid are the dominant elements, cost $35.7 billion in a total health budget of $49.6 billion in 1977 (Walsh 1978).

Home Health Services

In the United States the primary emphasis in health care services has been in acute short-term care and long-term institutional care. In contrast to Great Britain, the U.S. has not supported and developed home health services. In recent years public funds for nursing home care (institutional care) have increased markedly. In 1960 total revenues for the industry were $500 million, by 1970 they had increased 460 percent to $2.8 billion, and by 1974 revenues from all sources had reached an estimated $7.5 billion (Special Committee on Aging, United States Senate 1974). In fiscal year 1977, $12.5 billion was spent for nursing home care (Kane and Kane 1978). While expenditures for institutional care have increased sharply, expenditures for home health services under Medicare and Medicaid have remained very low. Utilization of home health services in the Medicare system has remained at less than 1 percent of insurance expenditures. In 1973 home health services accounted for about .7 percent ($64 million) of all Medicare expenditures. Home health services under Medicaid in 1973 amounted to $24 million or about .3 percent of all expenditures for Medicaid recipients (Reif 1977).

As mentioned above, home health services are not well developed in the United States. There is no comprehensive range of services readily available and accessible, and the current range of services do not meet the most pressing needs of the elderly population. Services are oftentimes fragmented; indeed, the public, as well as many health care professionals, is uninformed about the types of services available and where to go to obtain necessary assistance.

One of the greatest problems in the provision of home health care is the lack of funding for those services most often needed. To qualify for in-home health services, the person must need professional nursing or some other type of skilled professional care such as physical therapy. Services are provided primarily to those patients who are likely to improve or be rehabilitated; care of the "custodial" patient is specifically disallowed under Medicare. The total number of visits for all types of services is even limited to one hundred visits under Medicare, Part A, as a post-hospital service and one hundred visits per year under Medicare, Part B, with no requirement of prior hospitalization for those who can afford co-insurance (Special Committee on Aging, United States Senate 1972). Since the number of visits allowed includes visits by all personnel (nurses, physical therapists, social workers, and others), this plan in effect provides only for short-term care following an acute illness. Many of the same limitations that apply to Medicare home health benefits also apply to Medicaid. Medicaid emphasizes limiting home health care to those individuals who are acutely ill. In short, the elderly patient must be sick enough to require skilled professional services, but not sick enough to require too many visits or too much care. Medicare and Medicaid do not provide funds for those who most need services, the chronically ill with some degree of functional impairment.

Coverage for home health services by private insurance companies is uneven, limited, and frequently more restrictive than the coverage provided by Medicare. Charitable organizations make a significant contribution to the funding of home health care, but these contributions are not sufficient to provide assistance to the extent needed (Reif 1977).

There are considerable restrictions and deficiencies in home health services in the United States; consequently, thousands of elderly people are needlessly institutionalized because they need some relatively inexpensive assistance with homemaking services or other home health care that would enable them to remain in their home (Special Committee on Aging, United States Senate 1972).

The Growth and Development of the Nursing Home Industry

The lack of home health services and the emphasis on institutional care in the United States has brought about a tremendous increase in the number of institutionalized elderly in recent years. The number of nursing homes increased from 9,582 in 1960 to 23,000 in 1976, a 140 percent increase, and the number of nursing home beds increased 302 percent from 331,000 to 1,327,358 (Moss and Halamandaris 1977:7). Out of this increase a veritable industry has grown: the nursing home. Total expenditures for nursing home care have risen from $1.75 billion in 1967 to $12.5 billion in 1977 (Hickey 1980, Kane and Kane 1978).

Since there are many types of institutional facilities for the aged that provide a variety of services, a brief explanation and a definition of terms is in order at this point. Among the various types of long-term facilities are nursing homes, convalescent hospitals, convalescent homes, board and care homes, rest homes, and county homes. All long-term-care facilities provide one or more of the following services: (1) nursing care such as administration of medication, catheterizations, dressing changes, and other procedures under the direction of a physician; (2) personal care such as bathing, grooming, dressing, and assistance in walking and eating; (3) residential care, that is, room and board, laundry, and other personal amenities. The emphasis in the long-term-care facility is not on restoration, rehabilitation, and return to the community; some 80 percent of the aged who enter these institutions die there rather than in their own homes (Butler 1975). Instead, these long-term-care institutions exist primarily as permanent placement facilities, as do the continuing care wards or hospitals in Britain.

Of the various types of long-term-care institutions in the United States, the nursing home is the predominant institution, the one most frequently referred to in discussions of institutional care, both in professional and lay literature. A nursing home, as defined by the American College of Nursing Home Administrators, is an institution providing a protective and supervised environment, licensed to care for those persons who because of physical or mental conditions require a combination of health care services, personal services, and living accommodations that can best be made available through institutional facilities other than acute-care units of hospitals (Nursing Home Fact Book 1971). These services may include

skilled nursing care, medical care, assistance with medications and therapeutic diets, regular observation of the patient's physical and mental condition, personal assistance with bathing, dressing, grooming, walking and household activities, and a program of social and recreational activities.

Although the historical antecedents of the nursing home are somewhat difficult to trace, it appears that almshouses—the public poor houses of colonial America—were the historical progenitors of nursing homes. In both Britain and the United States, the care of the aged has been historically intertwined with the care of the poor and the destitute. In the early part of the eighteenth century, workhouses were established in England for the employment and maintenance of the poor, who were refused relief if they would not enter the workhouse (de Schweinitz 1943:63). By 1732 over fifty such workhouses had been built in England, and most of the larger colonial cities followed the mother country: Philadelphia in 1732, New York in 1734, and Charleston in 1735. Even after political separation, in 1788 New York state used the English Poor Law of 1722 as a model when it required each town to establish an almshouse (Freymann 1974:24). Although the original intent of the Poor Law legislation was to confine the able-bodied poor, it was usually cheaper and more efficient to confine all welfare cases, the sick, orphans, the insane, and the aged in the same workhouses. The proportion of aged in the workhouses in Britain and in the almshouses in the United States increased over the years because of a reduction of the children and able-bodied adults and because the number of old people in the population was increasing rapidly. In 1906, 45 percent of all the workhouse inmates in England were persons 60 years of age and over; of the 140,000 elderly persons in Poor Law institutions, only one or two thousand were in separate establishments for the aged (Townsend 1962).

In the United States the almshouses served as the place of last resort for parentless children, for the mentally retarded and the insane, for the aged who were infirm, and for strangers in the community who had no family and who had suddenly fallen ill (Rothman 1971). Special institutions were developed in time to care for the various categories of dependents who had been housed in the almshouses. In New York, for example, Bellevue took over the care of the acutely ill poor in 1848, the blind were removed from the workhouses in 1831, the mentally retarded in 1851, children in 1875, and the insane in 1890. By World War I, the

almshouse population was down to the aged, the infirm, and the chronically ill (Freymann 1974:20).

As immigrants poured into the U.S. in the nineteenth century and as the cities grew large and crowded, the almshouse appeared to be the perfect solution to the problems of unemployment and poverty. As the cities grew larger the almshouses also grew, both in numbers and in size. Conditions within deteriorated rapidly. In the state of New York, a committee investigated every city and county almshouse in 1857, and reported that nearly every one was badly constructed, poorly heated and ventilated, and that dependents, regardless of age, sex, or condition were crowded together in small, filthy rooms. Overcrowding was endemic. In one almshouse near Bellevue Hospital, officials desperately made lofts and basements into dormitories to make room for fifteen hundred residents. The investigators told the legislature that the great mass of poor houses were the most disgraceful memorials of the public charity, that domestic animals were usually more humanely provided for than the paupers in some of these institutions (Rothman 1971).

It was because of strong public reaction to conditions in the public poor houses that Congress, with the enactment of the Social Security Act of 1935, prohibited the payment of federal old-age assistance to any individual housed in public institutions. The effect of this legislation was the displacement of thousands of elderly people from public facilities to proprietary boarding homes. The proprietary home provided the only means by which welfare administrators could evade the law, thus privately owned, profit-making nursing homes were in a seller's market and grew rapidly: the nursing home industry was born (Freymann 1974:29–32).

The 1935 Social Security Act, one of the earliest major social welfare programs, provided the impetus for the beginning development of long-term-care facilities. For the first time in American history, people over the age of 65 had a guaranteed monthly income that enabled them to pay, at least in part, for some type of proprietary living accommodations, and this increased the demand for long-term-care facilities. By the mid-1950s, the number of homes for the aged had grown substantially, but the greatest growth came in 1965 with the enactment of Medicare and Medicaid. Nursing home regulations were established, and these regulations led to the disappearance of some of the smaller homes and the development of larger homes as big business, including several national hotel and motel chains, entered the field (Freymann 1974:31). In 1973, 74 percent of the

homes and 68 percent of the beds were proprietary, 22 percent of the beds were in nonprofit institutions, and 10 percent were in government institutions (Kane and Kane 1978). Within a few years, the nursing home industry had grown to a multi-billion dollar industry. Today it is the primary institution for the care of the chronically ill aged.

In the eighteenth, nineteenth, and the early twentieth centuries, many of the aged in both Britain and the United States received long-term care in the Poor Law hospital system or in public almshouses. Although both countries recognized that the care in these public poor houses was inadequate, and in many cases even disgraceful and inhumane, the approach to the care of the elderly in each country is due at least in part to the financing, organization, and philosophy of health care.

Beginning in the late nineteenth century, there was in Britain a national responsibility for public health; the 1911 National Health Insurance Act provided some personal medical care for the poor. During the early years of World War II, the medical profession and the government agreed on the need for reform in health services, and a plan for comprehensive health care for all people was embodied in the National Health Service Act of 1946; it began to operate on 5 July 1948. The express purpose of the NHS was to provide a comprehensive system of medical services directed toward the promotion of health, the prevention of disease, and the relief of illness through a wide array of institutional and community services. The NHS provided a structure for the organization and financing of geriatric medicine and made it possible to promote geriatrics as a specialty.

In the United States, by comparison, there has been a lack of government involvement both in matters of public health and in personal health care. Although there has been support for national health insurance by some political groups, it has been met by strong opposition to compulsory health insurance from the American Medical Association. Not until 1965, with the enactment of Medicare and Medicaid, did the federal government assume a major role in the financing of health care. Thus, whereas the National Health Service Act of 1946 made the British government responsible to establish a comprehensive health service, in the United States there is no plan to coordinate health care. That there is no central responsibility for care (as pointed out in Chapter 6) contributes to the low quality of care in many American nursing homes.

The difference in philosophy of health care in the two countries is also significant. In Britain, both philosophically and practically speaking, medicine in general and geriatric medicine in particular, have been concerned with the clinical, social, preventive, and rehabilitative aspects of health care, which concern has been to the advantage of the elderly. Today the geriatric service, in cooperation with social services, provides a comprehensive range of institutional, community, and domiciliary services to the elderly. In the United States the primary emphasis in health care services has been on acute, short-term, hospital-based care. The lack of interest in chronic, rehabilitative community care and services has been to the disadvantage of the elderly. There is no comprehensive range of services readily available, and the present range of services does not meet the most urgent needs of the elderly. For many of the chronically disabled elderly, the nursing home is often the only available option for care.