The Milbank Quarterly

Volume 73 Number 3, September 1995

In This Issue:

Paul D. Cleary, Editor

Contributors to recent issues of the Milbank Quarterly have analyzed the new role of acute care hospitals in the changing health care system. James C. Robinson ("The Changing Boundaries of the American Hospital", MQ 72:2), John D. Stoeckle ("The Citadel Cannot Hold," MQ 73:1), and Stephen M. Shortell, Robin R. Gillies, and Kelly J. Devers ("Reinventing the American Hospital," MQ 73:2) have written about the changing acute care hospital in a series edited by Rosemary Stevens. Stoeckle noted that the role and function of acute care hospitals have been changing over a period of several decades for a variety of clinical, technical, and organizational reasons. The pace of change, however, has accelerated dramatically in the past few years, partially as a result of market forces and, for a while, in anticipation of legislative passage of the comprehensive health care reform bill.

At the same time that the United States was struggling to change its health care system, the United Kingdom was engaged in reforming its National Health Service (NHS). The impact of the NHS reforms was to be almost as dramatic as the creation of that institution in 1948.

That there is no more knowledgeable or insightful observer of the health care system in the United Kingdom than Rudolf Klein will become apparent to readers of "Big Bang Health Care Reform," the lead article in this issue, which examines the nonfinancial costs and benefits of the 1991 reforms.

A cardinal feature of the NHS reforms was the attempt to build up a market within the framework of a universal, tax-financed system of care. In the second article of this issue, "Health System Reform in Industrialized Democracies," Dov Chernichovsky examines the recent tendency in industrialized democracies to combine universal access and control of spending with the advantages of competitive market principles.

An article published in the Milbank Quarterly several years ago, "The Case of the Disappearing Generalist" by Gordon T. Moore (MQ 70:2), scrutinized the important shift in emphasis to primary care that is occurring in the U.S. health care system. In "Teaching the Fundamentals of Primary Care," published here, Eric J. Cassell discusses the changes occurring in general medicine that have led to the need for new forms of training--right through the postgraduate level. Cassell analyzes the changes taking place in primary care and recommends ways to reform our approach to medical education so that it is more consistent with the emerging importance of primary care.

In "Expanding the Home Care Concept" (MQ 73:2), Rosalie A. Kane documented the increasing use of home health care and the expanding range of home health services. She emphasized as well that home care is no longer restricted to the "home," if by that is meant a private, independent living situation. Kane summarized the challenges to policy makers arising from the trends she describes.

Because of these trends, housing policy can have a critical role in inhibiting or facilitating the expansion of home-based care. In this issue, Sandra J. Newman, in "Housing Policy and Home-Based Care," notes that policy for publicly subsidized housing has begun to accommodate the need for long-term-care assistance, but that there are still significant gaps affecting the adequacy and safety of unsubsidized housing. These weaknesses, in turn, may inhibit the provision of home-based care. Newman makes a compelling case for more research on how housing, neighborhood conditions, and home-based care are interrelated in order to supply intelligent guidance for, and better coordination of, housing policy.