cially viable as individual going concerns, rather than in response to pure local need. This resulted in a significant excess of hospital service provision, for example, in and around London and a relative dearth in less affluent parts of the country. In the less well off provinces, many of today's hospitals are contained in buildings that began life as 'poor houses', often situated geographically in less than ideal sites for their current use. Although many would like to see 'Green-Field' redevelopment and relocation of acute services, the cost is prohibitive.PROBLEMSOne of the biggest obstacles to successful management of the NHS, and also to any analysis of its current well being, remains the significant lack of any valid information as to what the NHS does, how much it costs and where the money is spent. Indeed, it is perhaps surprising that 'the 1990 changes' were conceived and implemented as fast as they were, given the lack of information that was available in 1988. (Ham, 1996) Attempts were made at the start to ensure that hospitals began from a 'level playing field' so that they were in fair competition with one another, but the sometimes 10 fold differences in the early quoted costs for identical services in different hospitals had as much to do with differing costs of maintaining buildings as it had to do with a lack of agreement on accounting methods. There remains very considerable discrepancy in pricing. Different amounts are being charged for the same procedure in different facilities, even if they are in close proximity to each other. Further, because the NHS evolved organically since 1948 as an integrated provider of Health Care, the attempt to fragment it into different units, cross-charging one another, rapidly became beset by boundary disputes and uncertainties. There was much Cost-Shifting occurring, for example patients being discharged following Day Case Surgery with instructions to attend the GP for removal of s...
