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p There is a great variety of types of medical institutions in the USSR, their number reaching 100. The most widespread types are hospitals, polyclinics, and dispensaries. That is why, before going on to the characteristics of the public health services intended for different groups of the population, or established under particular economic and geographic conditions, it is worth taking a brief look at the main types of medical institutions.

p The leading curative and prophylactic institution in the Soviet Union is the incorporated hospital, i.e., an institution with an inpatient division and a polyclinic for outpatients.

p Naturally such hospitals are of different sizes and capacities, depending upon the character and size of the area which they serve. An incorporated hospital may have 100, 200, or 500 and more beds. Usually, however, especially in middle-sized towns, they have from 100 to 200 beds. This is not enough and the capacity of the hospitals must be enlarged because highly-skilled and specialised medical aid can best be provided by institutions which have all the basic specialised departments, which are equipped with up-to-date devices, apparatus and instruments for all forms of diagnostic, curative and prophylactic activity, and employ highlyskilled specialists of various types. Today the Soviet Union has hospital complexes with 600-800 and more beds and it is planned to build still larger hospitals with many specialised departments.

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p An incorporated hospital, as was already mentioned, has an inpatient section which, depending on its capacity, has various departments—therapeutic, surgical, obstetric and gynecological, neurological, ophthalmological, otolaryngological, etc. Large hospitals including a number of medical specialities have in addition ncurosurgical, nephrological, curdiological, pulmonological, gastroentcrological and other departments.

Experience and calculations show that in a large hospital (he most rational size of a department in such leading specialities as therapy and surgery, is 60 to 70 beds.

p Considerable importance is also attached to improving the functioning of the hospitals. In large curative and prophylactic institutions (hospitals, institutes, large sanitary and epidemiological centres, etc.) special departments or groups for studying the scientific organisation of work are established. They examine the working day of doctors of various specialities and by junior medical personnel, the distribution of personnel, suggest the optimum methods for the utilisation of material and technical resources, the organisation of the work of the medical staff, etc. An important problem in the organisation of public health work today is that of reducing the time doctors have to spend filling out various medical documents, especially case histories. For this purpose a set of technical innovations has been proposed, which simplify the keeping of the necessary records and save the doctor’s time. One of these is the organisation of dictaphone centres in large hospitals. The dictaphone centre receives information from the hospital departments, records it on tape and reproduces it in appropriate documents, most commonly standard case history diagrams. Usually a special system of telephones and tape recorders is employed for this purpose. The dictaphone centres employ medical nurses who type the information into the case histories.

p Such a dictaphone centre is operating in one of Moscow’s largest mental hospitals—the P. I. Kashchcnko Mental Hospital—which has more than 2,500 beds and a staff of some 2,000 people, including about 200 doctors. Before the establishment of the dictaphone centre, the doctors used to spend 50 per cent of their time keeping medical records. Now, with the dictaphone centre and its 21 tape recorders, the 74 doctors save a lot of time. The experience of this particular dictaphone centre lias shown that it may also be used for making and keeping the medical records of other medical institutions located in the vicinity. For example, it already records the medical documents from another city hospital with 750 beds.

p A similar dictaphone centre has been organised in the regional hospital of Podolsk, a town near Moscow. All the departments of this large hospital are connected to the dictaphone centre which receives their information and keeps records. A special study of the effectiveness of this centre has shown that it has cut the time usually required to fill out the case histories and other necessary documents by more than a half. The time thus saved is now used by doctors for tasks requiring their medical skill.

Electronic computers, dictaphone centres and other means of mechanising hospital routine are being introduced on an ever growing scale since they help to save time and rationalise medical work.

p An integral part of an incorporated hospital is the polyclinic or, to be exact, the polyclinical division of the hospital. It should at once be noted that the polyclinic administers the greatest volume of medical aid to the population. The practice of recent years has shown that about 80 per cent of all patients received medical aid in the polyclinics and not more than 20 per cent were hospitalised. Moreover, those patients who are referred to hospitals, go through the polyclinics as well. Thus the polyclinic, which is in most cases considered a structural unit, belonging to an incorporated hospital, plays a very important role in the Soviet public health system. There also exist independent polyclinics, i.e., not attached to hospitals.

p The polyclinic is the most important unit in the Soviet health service. Not a single country in the world has, as yet, as many polyclinics as the Soviet Union. Moreover, Soviet polyclinics differ from comparable outpatient departments in other countries in their capacity, structure, the nature of their activities and methods of administering medical aid.

p What is a Soviet polyclinic? It is an amalgamation of various outpatient services. It includes offices and 75 departmcnts of different medical specialities (internal diseases, surgery, nervous diseases, diseases of the ear, throat and nose, skin diseases, etc.), and diagnostic laboratories, offices and departments of physical methods of treatment, etc. To some extent the polyclinic resembles in its purpose or, to be exact, in the character of its work the type of group practice being more and more commonly adopted by doctors in the USA, Great Britain, France and other countries. It also resembles the health centres which were organised in Great Britain after the introduction, in 1948, of a state public health system.

p The polyclinic, as it exists in the USSR, however, has a number of advantages over the group practice, the health centres and other forms of medical aid available for outpatients abroad. The polyclinic is a very complex institution that has evolved in the Soviet Union over a number of years and earned itself a good reputation. It offers treatment by doctors of various specialities, diagnoses diseases and combines therapy with prophylaxis. It is certain to have the requisite modern diagnostic equipment, a laboratory and apparatus for modern methods of treatment. Moreover, many polyclinics, as was said above, are incorporated with hospitals.

p Another special feature of Soviet polyclinics is that they are centres of curative and prophylactic work for a definite area. Most polyclinics, especially in towns, are district polyclinics, i.e., they serve a definite administrative part of the town (in small towns and villages they serve the entire population). This method of territorial distribution of polyclinics is another example of the divisional principle of serving the population discussed in the preceding chapter.

p Depending upon its capacity, a polyclinic serves a different number of divisions—up till 20 or even more (it will be remembered that in towns a medical division usually covers an area inhabited by 4,000 people, including some 1,000 children). It is believed that in towns, especially in large ones, a polyclinic should be capable of dealing with 1,600 or more patients a day.

p Everything that was said about polyclinics applies both to independent ones and those attached to hospitals. In the USSR hospitals (with polyclinics or having no polyclinical department) are divided into general and specialised hospitals. Specialised hospitals are usually those intended for 76 treating patients with tuberculosis, infectious diseases, mental disorders, etc. This does not mean, however, that there are no separate hospitals or clinics, i.e., medical institutions attached to higher medical schools and medical research institutes, intended for groups of patients with definite types of ailments. There are such clinics or separate hospitals, which may also he called specialised in, practically, all medical fields.

p A discussion was recently held in the press about the correlation between specialised hospitals, i.e., those intended for treating patients of one type ol ailment, and general hospitals, i.e., those having various specialised departments. Without going into the details of the discussion, which was started by Academician A. N. Bakulev, a prominent Soviet surgeon, and attracted the attention of many prominent scientists and practical public health workers, it should be noted that most of them were in favour of large hospitals, since there it is possible to combine various forms of medical aid and organise co-operation of various specialists, and since more favourable conditions exist there for setting up centralised diagnostic and therapeutic services in which polyclinics function as hospital departments.

p The question of hospitals and polyclinics is, obviously, closely connected with one of the most pressing problems of modern medicine, namely, specialisation. In the USSR specialisation is rightfully considered one of the decisive means of enhancing the quality of medical aid and providing the population with a highly-qualified medical service. The preference given to large (600 and more beds) hospitals will make an essential contribution to the development of specialisation.

p We must include as one of the basic public health institutions dispensaries, i.e., institutions for prophylaxis and administration of specialised medical aid in a number of diseases. In the USSR there are skin-and-venereal, oncological, neuropsychiatric, trachoma, goiter and exercise therapy dispensaries. These institutions, some of which have hospital beds, i.e., are in a position to administer both inand outpatient aid, work on the basis of the dispensary methods already discussed above. But, as was noted, the dispensary method is not limited to the work of the dispensaries alone; these are intended to supplement the dispensary services performed by all institutions of the USSR 77 public health system. The dispensaries concentrate their attention on the early detection of certain illnesses, early therapy, social and everyday help and, if necessary, regular visits to patients’ homes. Their functions include finding suitable jobs for the chronic patients giving expert opinion on the working capacity of patients and forensic testimony, as well as providing advisory aid to other curative and prophylactic institutions. The dispensaries co-operate with polyclinics and hospitals thereby considerably extending the iunction of the latter in administering the necessary medical aid to particular groups of patients.

p In discussing the material and technical base of Soviet public health in the preceding chapters we cited the most important figures including the number of hospital beds in ail the curative and prophylactic institutions. We noted the steady increase in the volume of medical aid provided to the population.

Table 8 shows the growth in the number of hospital beds and (heir specialisation.

“I" able 8 Specialisation of hospital beds (in thousands) Hospital beds 1910 I’J70 Absolute numbers Per 10.000 population Absolute numbers Per 10,000 population Total number of beds 790.9 40.2 2,003.3 109.2 Including: Internal diseases patients 102.1! 5 2 544.0 22 . 3 Surgical patients 99.4 i”) . 1 351.2 14.4 Oncological patients 1.7 0.1 40.0 1.9 Gynecological patients 33.0 1.7 151.5 (i 3 Tuberculosis patients 34.0 1.7 271.9 11.1 Infectious diseases patients 91.3 4.<S 198.3 8.1 Children with noninfectious diseases 52.5 2.7 324 . 8 13.3 I ’"ye patients 1:5.4 0.7 39.3 1.6 Otolaryngological patients 6.9 0.4 39 . 7 1.6 Ski n-and- venereal patients 15.4 0.8 52.8 2.2 Neurological patients 10.0 0.5 71.5 2.9 Mental patients 82.9 2.2 207.!) 11.0 Pregnant and parturient women 113.5 5.8 198.0 8.1 78

p We can see that since 1940 (before the Second World War) there has occurred a rather intensive specialisation of hospital beds. The degree of specialisation was particularly high in surgery. Neurosurgery, oncology, nephrology, etc., were also developing rapidly.

p At the same time there has been a further differentiation within the therapeutic disciplines. Specialised cardiological, rheumatological, gastroenterological, pulmonological and other internal disease institutions (hospital departments, clinics, etc.) are being established.

p Specialisation also covered the outpatient and polyclinical services. This is most clearly manifested in the organisation of specialised offices and departments in polyclinics and, as was mentioned above, in the establishment of specialised dispensaries.

p Among specialised outpatient and polyclinical institutions, either independently or as parts of other institutions, that have become widespread of late are cardiorheumatological offices and dispensaries, offices of intestinal infections in polyclinics, hematological offices, etc.

p In addition to specialised offices, dispensaries and other institutions intended to provide the population with skilled medical aid even in the rarer diseases, specialised medical aid centres designed for the population of whole regions or even several regions are now being organised in the USSR.

p Usually such centres combine polyclinical and hospital aid. Large specialised hospitals with 600 and more beds are now being built. Among them are hospitals for cardiosurgery, neuro-oncology, nephrology, chronic renal insufficiency, pulmonology, etc. Today, for example, there are more than 80 "renal centres" in the Soviet Union with up-to-date equipment, including such complex apparatus as the artificial kidney. Such centres for the rarer diseases usually arc established on the basis of large research institutes and serve the population of several regions and even republics. Thus, for example, the Institute of Cardiovascular Surgery of the USSR Academy of Medical Sciences is the chief centre of cardiovascular surgery. Thirty cardiosurgical centres have been established on the basis of large clinics and research institutes. The N. N. Burdenko Institute of Neurosurgery of the USSR Academy of Medical Sciences is the basic neurological centre; there are other centres in this speciality based on research institutions in this field, as well as large hospitals 79 and polyclinics. There arc also centres for the treatment of burns; here patients with severe burns receive highly-skilled aid.

Specialised interrepublican, republican and regional centres for various internal diseases are being established. Thus the specialisation of in- and outpatient aid in the Soviet Union is developing through the organisation of specialised departments at large hospitals, some of which simultaneously become centres in the field of medicine and the organisation of specialised complexes consisting of large hospitals and outpatient departments.

p In this small book we cannot possibly hope to mention all the forms of specialisation, but feel bound to dwell on one of its most widespread forms, namely, the Soviet first aid service.

p There is a widely ramified system of first aid stations and centres in the USSR. First aid stations are usually set up in cities with a population of 500,000 and more. These stations are well-equipped for rendering urgent, first aid, having a centralised controlling office and specialised conveyances (ambulances). All polyclinics have emergency aid centres, which also have special vehicles for emergency calls. Most of the vehicles are appropriately equipped, and have direct radio-telephone communications with the first aid stations. In large cities the first aid stations have hospitalisation offices which are always informed as to the free beds available in all hospitals, which have the facilities for accommodating and treating patients brought by ambulance.

p The ambulances are served by teams of medical workers headed by doctors, while we know some countries, where first aid is administered by policemen, cab drivers and other people who have had no medical training.

p Of late specialised first aid teams have been gaining in popularity; these teams are summoned for immediate medical aid and transportation of patients affected with definite diseases. Today there are more than 300 of such teams specialising in resuscitation, aid in heart attack, poisonings, first aid to children, etc.

p Urgent problems of emergency aid are studied by three research institutes, in Moscow, Leningrad and Kharkov. The Sklifasovsky First Aid Institute in Moscow has won 80 wide renown; it has a large hospital with various specialised departments and research laboratories.

p Since demands for emergency aid are great plans are now under consideration to expand the emergency aid services.

In addition to these services, large, and especially regional hospitals have air ambulance stations. The air ambulances carry specialists to accident victims or patients in very grave condition and requiring highly-skilled aid, or transport the accident victims and patients to hospitals. The air ambulance stations are particularly important and at times indispensable in the Far North and the vast steppes of Central Asia and Kazakhstan.

p Plans for developing health protection and medical science in the USSR provide for organising many new centres of specialised medical aid. For example, large clinical hospitals with polyclinics with 1,000 or more beds each are to be built in 1971-1975. Moreover, oncological dispensaries (450 and more beds each), lirst aid hospitals with resuscitation centres (600-1,000 and more beds each), specialised hospitals for restorative treatment with polyclinics and similar hospitals for children (360-520 beds each) are to be built during the same period.

It may be asked whether such extensive and long-term plans for developing the network of medical institutions in the USSR, including the construction of many specialised departments, hospitals and centres are really called for, seeing that, as has been shown, the health of the Soviet people is constantly improving. It would seem to follow that the need of the population for medical aid should decrease. Yet we speak about the considerable increase in number of the country’s different medical institutions as a considerable achievement, and note that the extent of all forms of medical aid administered to the people is growing every year. Whereas in 1955 some 600 million people sought medical aid at polyclinics and other outpatient institutions in Soviet towns, in 1967 the number of applications to these institutions for treatment amounted to nearly 1,250 million. This means that in the towns each person visited outpatient institutions an average of 10 times in 1967, about 7 times in 1955 and about 6 times in 1940 (before the war).

81 institutions indicate a deterioration in the health of the population? We have already noted that it does not. The increase in the number of applications to medical institutions shows that people attach greater importance to receiving highly competent medical advice and to being treated by specialists. Moreover, more and more healthy people come to medical institutions for consultation on problems of hygiene. Medical institutions are extending their prophylactic activities, and dispensary work. Our plans envisage placing the entire population of the Soviet Union under dispensary observation within the next 20 yeiirs. The accomplishment of this task requires a sharp increase in the number of different medical institutions. Hence, the growth of hospitals, polyclinics, dispensaries and other curative and prophylactic institutions in the Soviet Union.