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Current Chinese Economic Report Series

Lulu Zhang
Meina Li
Feng Ye
Tao Ding
Peng Kang

An Investigation
Report on Large
Public Hospital
Reforms in China
Current Chinese Economic Report Series
More information about this series at http://www.springer.com/series/11028
Lulu Zhang • Meina Li • Feng Ye
Tao Ding • Peng Kang

An Investigation Report
on Large Public Hospital
Reforms in China
Lulu Zhang Meina Li
Second Military Medical University Second Military Medical University
Shanghai, China Shanghai, China

Feng Ye Tao Ding

Second Military Medical University Second Military Medical University
Shanghai, China Shanghai, China

Peng Kang
Second Military Medical University
Shanghai, China

ISSN 2194-7937 ISSN 2194-7945 (electronic)

Current Chinese Economic Report Series
ISBN 978-981-10-0037-9 ISBN 978-981-10-0039-3 (eBook)
DOI 10.1007/978-981-10-0039-3

Library of Congress Control Number: 2015956544

Springer Singapore Heidelberg New York Dordrecht London

© Springer Science+Business Media Singapore 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt
from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
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authors or the editors give a warranty, express or implied, with respect to the material contained
herein or for any errors or omissions that may have been made.

Printed on acid-free paper

Springer Science+Business Media Singapore Pte Ltd. is part of Springer Science+Business Media
(www.springer.com)
Zhixin Dai, Jianzhen Liu, Xin Nong,
Jingrui Wang, Wenya Yu, Haiping Chen,
Chen Xue, Yang Ge, Bihan Tang, Yipeng Lv,
Zhipeng Liu. These authors also participate
in redaction, thank them for their hard work.
Preface

Public hospital reform is one of the five key elements of healthcare reform. Public
hospitals are the basis of our healthcare system so appropriate reform of public
hospitals will directly relate to whether healthcare reform is considered a success or
a failure. As centers of health services, public hospitals contain various contradic-
tions and problems, which form a “fortress” that prevents healthcare reform from
being carried out within.
The solution is a tracking research project designed to enact public hospital
reform, which was approved by the National Natural Science Foundation Commit-
tee as a key project in 2012. The project is entitled “Research on Public Hospital
Reform via Evidence-based Decision-making According to Multiple Complex
Adaptive Systems (CAS) Modeling of Public Welfare” (71233008). This report is
a key project of the National Natural Science Foundation independently undertaken
by a number of research universities. Through multiple CAS modeling of public
welfare, this project conducts independent research and academic assessments of
public hospital reform programs, supportive measures, and the effectiveness of
reform. The results of this research will be used only for academic reference.
The project comprised three stages. The first stage involved preparation and
preliminary design. The preliminary questionnaires were designed to suit the
purposes and content of the research project through extensive collection of rele-
vant information via literature database searches, brainstorming, the Delphi
method, field surveys, and various other methods. The survey objectives and
demands determined the research settings, which were 15 public hospitals in
Shanghai and 9 public hospitals in Beijing. We used stratified sampling to inves-
tigate three groups in the selected hospitals: administrative staff, medical staff, and
patients.
The second stage was a pre-investigation. We utilized the concentrated field
investigation method and administered the preliminary questionnaires in three
hospitals. Each questionnaire was completed independently and collected on-site

vii
viii Preface

in a timely fashion to prevent logical errors and omissions. This guaranteed a high
response rate and reduced non-response bias.
The third stage was the survey proper. According to sample size estimations, we
formulated an investigator plan and conducted survey personnel training. We then
conducted the centralized questionnaire survey on-site in selected hospitals,
performing timely quality control to ensure that the survey had good reliability
and validity. The Epidata software was used for data entry and the statistical
software packages of SAS and SPSS were used for data analysis. According to a
unified coding method, we collated and reviewed the recovered sample question-
naires and input the data into an established database. From there, we determined
the analysis strategies, including the contents of the analysis and the involved
variables. Upon choosing the right software for statistical analysis, we comprehen-
sively analyzed the data and then interpreted and summarized them to achieve our
research purpose.
Compared with other related domestic and foreign research, this research project
had three innovations. First, it interpreted the effectiveness of public hospital
reform from a multidimensional perspective, including patients, doctors, and hos-
pital administrators. Second, it involved a comparative analysis of the basic situa-
tion of large public hospitals in Beijing and Shanghai. Finally, it utilized multiple
CAS modeling of public welfare for public hospital reform, thereby opening up new
avenues for future research on public hospital reform.
This book comprises four sections and twenty chapters. The first section is a
general overview of the topic, including background information (Part I), an
investigation of Chinese public hospital reform (Part II), and basic information on
the present survey on large public hospital reform (Part III). The second section
comprises a series of survey reports on large public hospital reform (Chaps. 4, 5, 6,
7, 8, 9, and 10) on the following topics: public welfare, satisfaction, patients’
medical choices, medical staff welfare, two-way referral, multisite licenses, and
translational medicine development. The third section is comparative analysis of
the current situation of large public hospital reform (Chaps. 11, 12, 13, 14, 15, 16,
17, 18, and 19). The fourth and final section is an overall assessment and policy
recommendations (Chap. 20).
“The investigation report of large public hospital reform (2013)” is the result of
research by this task group; it is an example of the collective wisdom of this task
group and is the product of tireless research and mutual cooperation. The majority
of the task work was completed by researchers aiming to complete master’s degrees
or doctorates, and we sincerely thank them and the other research group members
for their hard work. At the same time, we would like to thank the Management
Science Department of the National Natural Science Foundation, the National
Health and Family Planning Commission, the General Logistics Department of
the People’s Liberation Army, and the Shanghai Municipal Health and Family
Planning Commission for their strong support of this research. Thank you also to
the leaders and colleagues of the various affiliations of the Second Military Medical
University, including the science departments, graduate school, Changhai Hospital,
Preface ix

Changzheng Hospital, Health Institute, and the Institute of Military Health

Management.
The research is also funded by the major program of National Natural Science
Foundation of China (L.Z., grant number 91224005), the major project of “12th
five-year plan” of People’s Liberation Army (L.Z., grant number AWS12J002), the
major project of National Natural Science Foundation of China (L.Z., grant number
71233008), the joint research project of major diseases of Shanghai health system
(L.Z., grant number 2013ZYJB0006). We expect this report to play a valuable role
in Chinese public hospital reform and encourage readers to think deeply about such
reform. We utilized a multidimensional perspective to crack the problem of public
hospital reform, particularly the issues of management reform in public hospitals,
the principles of government for healthcare inputs, the orientation of health insur-
ance development, and doctor–patient relationship transformation.

2015-9-17
Second Military Medical University Lulu Zhang
Shanghai, China
Contents

Part I Pandect
1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Research Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Survey Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.1 Research Objective . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.2 Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.3 Research Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.4 Research Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.5 Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.6 Technological Roadmap . . . . . . . . . . . . . . . . . . . . . . . 8
1.2.7 Conducting the Investigation . . . . . . . . . . . . . . . . . . . 9
1.3 Investigation Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Review of Chinese Public Hospital Reform . . . . . . . . . . . . . . . . . . . 13
2.1 Overview of Chinese Public Hospital Reform . . . . . . . . . . . . . . 13
2.2 Practical Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.1 Separation of Government Functions from Those
of Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.2 Separation of Management from Operations . . . . . . . . 20
2.2.3 Separation of Prescriptions from Dispensing
of Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2.4 Separation of the For-profit and Nonprofit Nature
of Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.3 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.1 Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.2 Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

xi
xii Contents

3 Basic Information Survey for Large Public Hospital Reform . . . . . 31

3.1 Basic Information on Medical Staff . . . . . . . . . . . . . . . . . . . . . 31
3.1.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.1.2 Economic Situation . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2 Basic Information on Patients . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.2 Economic Situation . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.3.1 Basic Information of Medical Staff . . . . . . . . . . . . . . . 37
3.3.2 Basic Information of Patients . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Part II Series of Survey Reports on Large Public Hospital Reform

4 Survey on Public Welfare of Public Hospitals . . . . . . . . . . . . . . . . . 43
4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.1.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.1.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.2 Perception of the Public Welfare of Public Hospitals . . . . . . . . 45
4.3 Expectations for Public Welfare of Public Hospitals . . . . . . . . . 45
4.3.1 Medical Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.3.2 Administrative Staff . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.4 Assessment of Public Welfare of Public Hospitals . . . . . . . . . . 52
4.4.1 Perceptions of the Current Implementation
of Public Welfare of Public Hospitals . . . . . . . . . . . . . 52
4.4.2 Perception of Public Hospitals’ Diagnosis
and Treatment Quality . . . . . . . . . . . . . . . . . . . . . . . . 52
4.4.3 Evaluation of Public Health Services
in Public Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4.5 Relationship Between Nonprofit and for-Profit Goals . . . . . . . . 54
4.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5 Survey of Outpatient Satisfaction with Large
Public Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.1.4 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2 Outpatient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2.1 Waiting Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2.2 Medical Staff Service Attitude . . . . . . . . . . . . . . . . . . 65
5.2.3 Diagnosis and Treatment Quality . . . . . . . . . . . . . . . . 67
5.2.4 Medical Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Contents xiii

5.2.5 Hospital Environment . . . . . . . . . . . . . . . . . . . . . . . . 69

5.2.6 Overall Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.3 Factors That Influence Satisfaction . . . . . . . . . . . . . . . . . . . . . 72
5.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6 Survey on Health-Seeking Behavior in Large
Public Hospital Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.1.4 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.2 Motivation for Health-Seeking Behavior . . . . . . . . . . . . . . . . . 77
6.2.1 Seeking Medical Treatment in the Past Year . . . . . . . . 77
6.2.2 Influence of Social Relationships
on Health-Seeking Behavior . . . . . . . . . . . . . . . . . . . . 78
6.2.3 Not Seeking Medical Treatment When Ill . . . . . . . . . . 78
6.2.4 Reasons for Not Seeking Medical Treatment
When Ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.3 Current Situation of Health-Seeking Behavior . . . . . . . . . . . . . 79
6.3.1 Burden of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.3.2 Medical Institution Choices for Ailments
or Common Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.3.3 Medical Institution Choices for Chronic Diseases . . . . 80
6.3.4 Medical Institution Choices for Serious Illnesses . . . . . 81
6.4 Factors Influencing Health-Seeking Behavior . . . . . . . . . . . . . . 81
6.4.1 Diagnosis and Treatment Quality . . . . . . . . . . . . . . . . 84
6.4.2 Medical Environment . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.4.3 Habit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.4.4 Medical Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.4.5 Medical Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.4.6 Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.4.7 Waiting Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.4.8 Self-rated Health Status . . . . . . . . . . . . . . . . . . . . . . . 86
6.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7 Survey on Well-Being of Doctors in Large Public Hospitals . . . . . . 89
7.1 Job Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7.1.1 Job Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7.1.2 Factors That Influence Satisfaction . . . . . . . . . . . . . . . 91
7.2 Well-Being of Doctors in Large Public Hospitals . . . . . . . . . . . 91
7.2.1 Workload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7.2.2 Doctors and Patients . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.2.3 Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
xiv Contents

7.3 Daily Working Time, Job Satisfaction,

and Expected Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
7.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
8 Survey on Two-Way Referrals Between Large Public
Hospitals and Community Health Service Centers . . . . . . . . . . . . . 109
8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.1.1 Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.1.2 Content and Method . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.1.3 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.2 Basic Information on Patients and Doctors . . . . . . . . . . . . . . . . 110
8.2.1 Basic Information on Patients . . . . . . . . . . . . . . . . . . . 110
8.2.2 Basic Information on Doctors . . . . . . . . . . . . . . . . . . . 112
8.3 Doctors’ and Patients’ Cognitions on Two-Way Referral . . . . . . 114
8.3.1 Patients’ Cognitions . . . . . . . . . . . . . . . . . . . . . . . . . . 114
8.3.2 Doctors’ Cognitions . . . . . . . . . . . . . . . . . . . . . . . . . . 118
8.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
9 Survey on Multisite Licenses in Large Public Hospitals . . . . . . . . . 123
9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
9.1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
9.1.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
9.1.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
9.1.4 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
9.2 Large Public Hospital Doctors’ Knowledge
of Multisite Licenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
9.2.1 Knowledge of Policies . . . . . . . . . . . . . . . . . . . . . . . . 125
9.2.2 Knowledge of Multisite Practice . . . . . . . . . . . . . . . . . 126
9.3 Large Public Hospital Doctors’ Demand
for Multisite Licenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
9.3.1 Doctors’ Work Burden . . . . . . . . . . . . . . . . . . . . . . . . 126
9.3.2 Difficulty of Obtaining Medical Services . . . . . . . . . . . 126
9.4 Factors Influencing Large Public Hospital
Doctors’ Preferences for Multisite Licenses . . . . . . . . . . . . . . . 128
9.4.1 Hospital Policy Bias . . . . . . . . . . . . . . . . . . . . . . . . . . 128
9.4.2 Importance of Doctors’ Mobility . . . . . . . . . . . . . . . . . 128
9.4.3 Doctors’ Desire for Multisite Practice . . . . . . . . . . . . . 129
9.4.4 Doctors’ Willingness to Practice at Multiple Sites . . . . . . 131
9.4.5 Number of Additional Institutions that Doctors
Are Willing to Practice At . . . . . . . . . . . . . . . . . . . . . 131
9.4.6 Supporting Policies . . . . . . . . . . . . . . . . . . . . . . . . . . 131
9.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Contents xv

10 Survey on Translational Medicine in Large Public Hospitals . . . . . 137

10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.1.1 Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.1.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.1.3 Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.1.4 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2 Medical Staff’s Knowledge of Translational Medicine
in Large Public Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2.1 Administrative Staff . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2.2 Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
10.2.3 Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
10.3 Medical Staff’s Views on the Necessity of Translational
Medicine Centers in Large Public Hospitals . . . . . . . . . . . . . . . 144
10.3.1 Administrative Staff . . . . . . . . . . . . . . . . . . . . . . . . . . 144
10.3.2 Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
10.3.3 Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
10.4 Understanding of Research-Oriented Hospitals . . . . . . . . . . . . . 149
10.4.1 Administrative Staff’s Understanding
of Research-Oriented Hospitals . . . . . . . . . . . . . . . . . . 149
10.4.2 Doctors’ Understanding of Research-Oriented
Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
10.4.3 Nurses’ Understanding of Research-Oriented
Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
10.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Part III Conclusions

11 Overall Assessments and Policy Recommendations . . . . . . . . . . . . . 179
11.1 Overall Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
11.2 Suggestions to Further Encourage Public Hospital Reform . . . . 183
11.2.1 Perfect the Healthcare System and Optimize the
Structure of Medical Resources . . . . . . . . . . . . . . . . . 183
11.2.2 Promote Higher-Level Reform and Achieve
Fundamental Improvements in Institutional
Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
11.2.3 Accelerate the Establishment of Sustainable Public
Hospital Funding Mechanisms and a Research-Based
Payment System and Improve the Welfare of Public
Medical Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . 184
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
 Part I
Pandect
Chapter 1
Background

1.1 Research Background

The Ministry of Health and five other ministries jointly issued a document titled
“guidelines for public hospital reform” in February 2010 and established 22 pilot
reform cities throughout China. The document required all local reforms to adhere
to public welfare goals, attempt to resolve the problems with the administrative
system and compensation mechanisms, and promote four types of separation (i.e.,
separation of government functions from those of institutions, separation of man-
agement from operations, separation of prescriptions from dispensing of drugs, and
separation of the for-profit and nonprofit nature of hospitals), thereby signifying a
determination for China to enact reform of public hospitals (Zhao and Feng 2010).
The Chinese People’s Liberation Army (CPLA) actively responded to this national
call, and drawing on the resources of military hospitals (e.g., their high quality
human resources and research conditions), proposed the concept of a “research-
oriented hospital.” Then, the CPLA led a pilot construction of research-oriented
hospitals. The proposed research-oriented hospital represented the high require-
ments for public hospitals reform—namely, that public hospitals should not only
drive the development of medical technology to benefit humanity but also return to
a path of public welfare, continually limiting costs while maximizing the public
benefit. The research-oriented hospital immediately garnered the attention of the
State Ministry of Health (Guo-Quan 2010). The Chinese Research-oriented Hospi-
tal Association was formally established in 2013. It was launched by the Vice
Minister of the General Logistics Department of the CPLA, Qin Yinhe, in 2012,
with support from the Ministry of Health and the Health Department of the General
Logistics Department; it was built over one year. Since then, construction of
research-oriented hospitals has been in full swing across the country, pushing
public hospital reform to new heights. The Army Institute for Health Management
seized this opportunity, drawing on ten years of macro-level health policy research,
to focus on public hospital reform and research-oriented hospital construction (Liu

© Springer Science+Business Media Singapore 2016 3

L. Zhang et al., An Investigation Report on Large Public Hospital Reforms in China,
Current Chinese Economic Report Series, DOI 10.1007/978-981-10-0039-3_1
4 1 Background

2004). With the support of the National Natural Science Foundation and the Health
Department of the General Logistics Department, the Army Institute for Health
Management undertook a key project original proposed by the National Natural
Science Foundation, entitled “Research on Public Hospital Reform via Evidence-
Based Decision-Making According to Multiple Complex Adaptive Systems (CAS)
Modeling of Public Welfare” (71233008), along with a theory monograph entitled
“Research-oriented Hospital Transformation Mechanisms and Management.”
Public hospital reform was in its third year in 2013 when the country carried out
a mid-term evaluation of pilot cities for public hospital reform to assess the
effectiveness of said reform; the specific goal of this evaluation was to obtain
experiences of success and failure among the pilot cities (Liu et al. 1999). Because
governmental assessments are mainly at the governmental level, their results often
have an excessively macro view. In other words, the actual situation of public
hospitals, especially the personal experiences of doctors and patients, is generally
not obtained. To obtain a third-party perspective, the Army Institute for Health
Management established a research group to conduct an in-depth field investigation
of public hospitals in Beijing and Shanghai, striving to provide a more independent
and objective assessment for government decision-making.

1.2 Survey Program

1.2.1 Research Objective

We sought to obtain knowledge of the current status of the public welfare of public
hospitals and to understand the public’s awareness and attitudes towards the public
welfare of these hospitals. Furthermore, we aimed to evaluate changes in the public
welfare of public hospitals after the implementation of medical and health system
reform, thereby providing basic information for furthering implementation and
evaluation of such reform.

1.2.2 Research Design

We selected the most developed cities in China (Beijing and Shanghai) as research
settings, surveying nine public hospitals in Beijing and 15 in Shanghai. We chose
these cities because, in them, public hospital resources are abundant and widely
distributed, the overall number of hospitals is high, the hospital system designs are
normal, and the difficulty and costliness of seeking medical care is the most
concentrated problem. Furthermore, the reform of public hospitals is somewhat
more mature in these two cities, thereby better reflecting the actual situation of
public hospital reform (Yip et al. 2012). Our research task was to establish a project
group to devise a research plan and organize investigators to coordinate with the
1.2 Survey Program 5

Shanghai Health Bureau, the Health Department of the Chinese People’s Liberation
Army (CPLA), and several public hospitals in Shanghai and Beijing to perform
mid-term management and check the survey results. This questionnaire survey was
designed to assess four dimensions of public hospital reform—hospital manage-
ment, administrative personnel, medical staff, and patients—for a total of 18 differ-
ent questionnaires. The large amount information and comprehensiveness of the
questionnaire can provide true, detailed, and objective data for this study of public
hospital reform.

1.2.3 Research Content

The survey questionnaires comprised 21 scales, as follows: (1) the Basic Situation
of Hospitals Questionnaire; (2) Transformational Medicine Institute Questionnaire;
(3) Public Hospital Reform Policy Questionnaire; (4) Hospital Diagnosis and
Treatment Quality Questionnaire; (5) Transformational Medicine Cognition Ques-
tionnaire (Administrator version); (6) Public Hospital Business Target and Non-
profit Goal Questionnaire (Administrator version); (7) Expected Role of Public
Hospitals Questionnaire (Administrator version); (8) Transformational Medicine
Cognition Questionnaire (Medical Staff version); (9) Public Hospital Business
Target and Nonprofit Goal Questionnaire (Medical Staff version); (10) Doctors’
Job Satisfaction and Expected Payment Questionnaire; (11) Two-Way Referral and
Multisite Practice Questionnaire; (12) Expected Role of Public Hospitals Question-
naire (Medical Staff version); (13) Evaluation of Factors Affecting Public Hospital
Satisfaction Questionnaire (Medical Staff version); (14) Evaluation of Factors
Affecting Public Hospital Satisfaction Questionnaire (Outpatient version);
(15) Patient Health Services Satisfaction Questionnaire (Inpatient version);
(16) Patient Health Services Satisfaction Questionnaire (Outpatient version);
(17) Public Hospital Welfare Function Orientation Questionnaire; (18) Public Hos-
pital Health Expenditure Payment Questionnaire; (19) Patient Medical Treatment
Patterns and Influencing Factors Questionnaire; (20) Medical Referral Content
Questionnaire; and (21) Patient Attitudes Toward Multisite Practice Questionnaire.
According to the research objectives, these 21 scales were divided into 4 cate-
gories, with the following specific classifications: (1) hospitals’ overall situation
(scales 1–4 in Table 1.1); (2) administrator questionnaires (scales 5–7); (3) medical
staff questionnaires (scales 8–13), among which scales 10 and 11 were only for
physicians; and (4) patient questionnaires (scales 14–21), among which scale
14 was designed only for outpatients and scale 15 only for inpatients.

1.2.4 Research Scope

The settings of the research include 15 hospitals in Shanghai and 9 in Beijing

(Figs. 1.1 and 1.2).
6 1 Background

Table 1.1 Research participants and questionnaires

Research
subject Questionnaires
Hospitals (1) Basic situation of hospitals questionnaire
(2) Transformational medicine institute questionnaire
(3) Public hospital reform policy questionnaire
(4) Hospital diagnosis and treatment quality questionnaire
Administrative (5) Transformational medicine cognition questionnaire (administrator
staff version)
(6) Public hospital business target and nonprofit goal questionnaire (admin-
istrator version)
(7) Expected role of public hospitals questionnaire (administrator version)
Medical staff (8) Transformational medicine cognition questionnaire (medical staff
version)
(9) Public hospital business target and nonprofit goal questionnaire (medical
staff version)
(10) Doctors’ job satisfaction and expected payment questionnaire
(11) Two-way referral and multisite practice questionnaire
(12) Expected role of public hospitals questionnaire (medical staff version)
(13) Evaluation of factors affecting public hospital satisfaction questionnaire
(medical staff version)
Patients (14) Evaluation of factors affecting public hospital satisfaction questionnaire
(outpatient version)
(15) Patient health services satisfaction questionnaire (inpatient version)
(16) Patient health services satisfaction questionnaire (outpatient version)
(17) Public hospital welfare function orientation questionnaire
(18) Public hospital health expenditure payment questionnaire
(19) Patient medical treatment patterns and influencing factors questionnaire
(20) Medical referral content questionnaire
(21) Patient attitudes toward multisite practice questionnaire

The research participants included hospitals, hospital administrative personnel,

medical staff, and patients (Table 1.1).

1.2.5 Organizational Structure

1.2.5.1 Research Group Members

The research group has nine members, including three each of professors, lecturers,
and master’s degree graduates. The three professors were Director Zhang Lulu of
the Institute of Military Health Management, Second Military Medical University;
Dean Li Jing of Changhai Hospital, an affiliation of Second Military Medical
University; and Vice President Xiang Yaojun of Changhai Hospital, which was
1.2 Survey Program 7

Fig. 1.1 Survey range of public hospitals in Shanghai

Fig. 1.2 Survey range of public hospitals in Beijing

8 1 Background

also an affiliation of Second Military Medical University. The three lecturers were
Li Mina, Ding Tao, and Dai Zhixin, all of the Institute of Military Health Manage-
ment, Second Military Medical University. Finally, the three master’s degree
graduates were Liu Jiazhen, Nong Xin, and Ye Feng.

1.2.5.2 Research Hospital Contact Officers

This investigation involved 24 hospitals. Within each hospital, we had an

established liaison, who was a unit staff member, mostly from the upper hospital
leadership layers or core departments, familiar with the hospital’s situation to
ensure that the questionnaire was completed accurately. Each hospital project
group designated one person to follow up on research progress who was responsible
for making contact with the hospital liaison.

1.2.6 Technological Roadmap (Fig. 1.3)

Document analysis
Draft questionnaires on public welfare of public hospitals
Delphi method

Pilot survey
Final questionnaires on public welfare of public hospitals
Statistical analysis

Results of assessment of public welfare of public

hospitals

Epidata, Effect of public Personnel awareness and

SPSS, and SAS hospital reform attitude towards the public
welfare of public hospitals

Conclusion of public hospital welfare survey

Fig. 1.3 Technological roadmap of the research

1.2 Survey Program 9

1.2.7 Conducting the Investigation

1.2.7.1 The First Stage (February 2013 to April 2013): Preparation

and Preliminary Design

Preliminary questionnaires suitable for the research purpose and content were
designed through extensive information gathering via literature database searches,
brainstorming, the Delphi method, field surveys, and various other methods. The
questionnaires were classified into three categories: administrator questionnaires
(six scales, combined into codes of A01, A02, and A03), medical staff question-
naires (seven scales, combined into codes of D01, D02, and D03), and patient
questionnaires (seven scales, combined into codes of P01, P02, P03, P04, and P05).
The survey objectives and actual demand determined the research areas, which
were 15 public hospitals in Shanghai and nine in Beijing. We used stratified
sampling to investigate three aspects of selected hospitals: administrators, medical
staff, and patients.

1.2.7.2 The Second Stage (April 2013 to May 2013): Pre-investigation

We utilized the concentrated field investigation method and issued the preliminary
questionnaires in three hospitals. Each questionnaire was independently completed
and recovered on-site in a timely fashion to prevent logical errors and omission; this
guaranteed a high response rate and reduced non-response bias.
Two hundred questionnaires were sent to research participants, and a total of
190 were returned. All returned questionnaires were complete enough to use in the
analysis. The questionnaire was found to be well designed, given that a few
questions were modified after the pre-investigation. Through the pre-investigation,
we learned what respondents would find difficult on the questionnaires, thereby
allowing us to devise countermeasures for these difficulties in a timely fashion.

1.2.7.3 The Third Stage (June 2013 to July 2013): Survey

According to sample size estimation, we formulated an investigation plan and

performed survey personnel training. The centralized questionnaire survey was
conducted on-site in the selected hospitals and was subjected to timely quality
control to ensure that it had good reliability and validity. A total of 11,090
questionnaires were issued and 9907 questionnaires were recovered.
The Epidata program was used for data entry, while the statistical software
packages SAS and SPSS were used for data analysis. According to a unified method
of coding, we collated and reviewed the recovered questionnaires and input the data
into an established database. Then, we determined the analysis strategies, including
the analysis content and involved variables. Upon choosing the appropriate
10 1 Background

software for statistical analysis, we performed a comprehensive analysis of the data,

and then interpreted and summarized it to achieve the research purpose.

1.3 Investigation Results

1. A large-scale investigation on public welfare of public hospitals in Shanghai and

Beijing was conducted. The research objectives covered four levels: hospitals,
hospital administrators, medical staff, and patients.
2. This field survey began in July 19, 2013, and lasted for two months. The field
investigation was carried out in two municipalities (Beijing and Shanghai), with
11,090 questionnaires being distributed and 9907 questionnaires being
recovered.
3. Data obtained related to the comparison of hospital performance before and after
the reform and cognitive data on public hospital reform measures of the four
groups (hospitals, hospital administrators, doctors, and patients). Furthermore,
we obtained data on the key performance targets of public hospital reform.
(a) The survey on public welfare of public hospitals showed that patients,
doctors, and administrative staff all considered that public hospitals should
contribute to public welfare. The majority of people believed that, cur-
rently, public welfare is provided by public hospitals, although the fairness
and availability of medical services are only adequate.
(b) We found that most people think that doctors’ occupational morals, clinical
results, and treatment costs are important factors affecting the public
welfare of public hospitals. Other factors included appropriate examina-
tions; reasonable prescriptions and treatment procedures given in a reason-
able amount of time; privacy protection; and the number of free clinics.
(c) The survey on hospitals’ service quality showed that the vast majority of
people considered patients’ diagnoses, treatment outcomes, and treatment
procedures to be reasonable. Notably, the frequency of hospital medical
accidents was low, at about 5–9 cases per year.
(d) The survey on hospitals’ service suitability showed that patients’ medical
costs, privacy protection, examination appropriateness, and patient cost
relief were all reasonable and reflective of good public welfare. However,
the quality of the annual free medical consultations and public health
medical rescues were considered unsatisfactory.
(e) The survey on public hospitals’ welfare function orientation found that
nearly 80% of patients deemed public hospitals as needing to offer more
control over drug use and medical checks by doctors.
(f) The factors influencing urban residents’ medical behavior were medical
insurance, income, self-rated health status, education, region, etc. Specifi-
cally, having insurance reduced the prices of patients’ medical services and
guided people to choose better-quality large hospitals even when there was
References 11

no increase in their income (Lu and Hsiao 2003). Higher income signifi-
cantly reduced the probability of people choosing basic health services
institutions and increased the probability of their going to better hospitals.
People with poor self-rated health were more sensitive to their physical
conditions and their medical service quality requirements were relatively
high, so they tended to visit large hospitals of better quality (Fayers and
Sprangers 2002). Education level influenced treatment selection in a similar
way: people with high-level educations paid more attention to their health
and took it more seriously, so they chose a better quality hospital (Gibson
et al. 2005).
(g) The survey on doctors’ job satisfaction found that most doctors (over 95%)
worked for more than 40 h per week. Furthermore, 60% of doctors were not
satisfied with their work.
(h) The survey on the balance between for-profit and nonprofit goals of public
hospitals showed that nearly half of medical staff considered that hospitals’
for-profit goals could not be balanced with their nonprofit goals and that the
external revenue of public hospitals would affect public hospitals’ welfare.
(i) Advanced technology is an essential aspect of public hospitals, which must
translate scientific research achievements into treatment technologies and
specifications for such technology (Chaudhry et al. 2006). The survey on
administrative and medical staff’s cognitions on translational medicine
showed that more managers and senior-level doctors knew about transla-
tional medicine compared with general practitioners and nurses.
(j) The survey on multisite practice policy showed that doctors are highly
concerned about and supportive of multisite practice. Doctors believed that
this policy was conducive to improving the social value of medical staff,
optimizing allocation of health resources, and improving medical personnel
labor value. However, they still had doubts about the implementation
difficulty and effects of a multisite practice policy (Luo et al. 2012; Liu
and Wang 2011).

References

Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S. C., & Shekelle,
P. G. (2006). Systematic review: Impact of health information technology on quality, effi-
ciency, and costs of medical care. Annals of Internal Medicine, 144, 742–752.
Fayers, P. M., & Sprangers, M. A. (2002). Understanding self-rated health. The Lancet, 359,
187–188.
Gibson, N., Cave, A., Doering, D., Ortiz, L., & Harms, P. (2005). Socio-cultural factors influenc-
ing prevention and treatment of tuberculosis in immigrant and aboriginal communities in
Canada. Social Science & Medicine, 61, 931–942.
Guo-Quan, R. (2010). Constructing research-oriented hospital: Measures and effectiveness
[J]. Hospital Administration Journal of Chinese People’s Liberation Army, 10.
Liu, Y. (2004). China’s public health-care system: Facing the challenges. Bulletin of the World
Health Organization, 82, 532–538.
12 1 Background

Liu, Y., & Wang, L. (2011). Thinking of multiple-point practice pilot policy in the new healthcare
reform. Chinese Hospital Management, 31, 1–2.
Liu, G., Cai, R., Zhao, Z., Yuen, P., Xiong, X., Chao, S., & Wang, B. (1999). Urban health care
reform initiative in China: Findings from its pilot experiment in Zhengjiang City. International
Journal of Economic Development, 1, 504–525.
Lu, J.-F. R., & Hsiao, W. C. (2003). Does universal health insurance make health care
unaffordable? Lessons from Taiwan. Health Affairs, 22, 77–88.
Luo, J. N., Wang, Y. L., Deng, Z. Y., Bei, W., & Li, L. D. (2012). Analysis of present situation and
countermeasures of multiple-point practice in Shanghai. Chinese Journal of Health Policy, 4,
26–31.
Yip, W. C.-M., Hsiao, W. C., Chen, W., Hu, S., Ma, J., & Maynard, A. (2012). Early appraisal of
China’s huge and complex health-care reforms. The Lancet, 379, 833–842.
Zhao, H., & Feng, X. (2010). Health-care reform in China. Chinese Economy, 43, 31–36.
Chapter 2
Review of Chinese Public Hospital Reform

2.1 Overview of Chinese Public Hospital Reform

China has experienced a tortuous public hospital reform process. Since the 1950s,
China has repeatedly attempted extensive reforms. Such reforms comprise four
stages (Yip et al. 2010). In the first stage, from 1950 to 1980, subsequent to the
pre-reform phase, reform focused on fairness of and accessibility to health services.
Because of the planned economic model, most hospitals utilized financial compen-
sations to take on numerous social functions. In the late 1960s, the reform focused
more on promoting medical and health services in rural areas, ensuring that almost
all communes had established hospitals. However, because of a lack of government
subsidies, it was difficult to compensate for the shortage of medical resources.
Moreover, because of an inadequate supply of medical services, poor-quality
medical treatment became a principal contradiction of public hospitals. In the
second phase, from 1980 to 1996, reform was aimed at reducing financial burdens,
decentralizing management rights, and mobilizing the hospital enthusiasm.
Because of the market economy, the reform was aimed at reducing government
spending, so the hospitals followed an enterprise reform. In April 1985, the
Ministry of Health issued a report on the number of policy issues of health reform;
in January 1989, the Ministry of Health and five other ministries issued a report
detailing issues related to the expansion of health services. Then, in 1992, another
report on the opinions on deepening the health reform was issued to encourage
hospitals to operate independently. With the decline in government spending,
personal burden for patients became increasingly heavy and medical services
were no longer as fair. The “economic man” behavior of hospitals was worsening,
service expensiveness was becoming an ever-greater problem, and social unrest
with the system was increasing. In the third phase, from 1997 to 2008, health
resources were often wasted and there was a clear lack of government responsibil-
ity. By combining a planned economy with a market economy, public reforms were
enacted, aimed at alleviating the difficulty and expensiveness of nonprofit

© Springer Science+Business Media Singapore 2016 13

L. Zhang et al., An Investigation Report on Large Public Hospital Reforms in China,
Current Chinese Economic Report Series, DOI 10.1007/978-981-10-0039-3_2
14 2 Review of Chinese Public Hospital Reform

institutions. In January 1997, under the CPC Central Committee and State Council
on Health Reform and Development, reforms were made to clarify the roles and
responsibilities of the government and hospitals and build up their operating
mechanisms. In February 2000, the State Council, specifically eight government
departments, issued guidelines on urban medical and health system reform and has
since published more than a dozen supporting documents. In July 2000 and 2001, a
reform forum was held in Shanghai. Moreover, three reform work conferences in
Qingdao issued a document called “opinions on how urban health institutions
should be managed,” which suggested that hospital financing, taxes, and service
price management policies should acquire operational autonomy. After this round
of reforms, the difficulty and expensiveness problems eased, but the “economic
man” behavior of hospitals continued. In the fourth stage, since 2009, there has
been a clear government-led healthcare reform aimed at improving public welfare.
In 2009, the CPC Central Committee and State Council on Deepening the Views of
the Medical and Health System was established and issued a document entitled “the
recent focus on medical and health system embodiment (2009–2011)”; on February
23, 2010, the Ministry of Health and five other ministries jointly issued the
“guidelines on the reform of public hospitals.” In March 2011, the State Council
issued the “2011 reform of public hospital working arrangements,” which clearly
designated separations of management and surveillance, administration and oper-
ations, treatment and medication, and profitability and nonprofitability as “the focal
point[s] of the reform of public hospitals, nonprofit health services persist.”
On the whole, public hospital reform was closely related to socioeconomic
development; it began with a low level of coverage, giving priority to efficiency,
before moving to emphasizing a balance of efficiency and fairness, and finally to a
public welfare spiraling process.

2.2 Practical Measures

2.2.1 Separation of Government Functions from Those

of Institutions

The separation of management and surveillance sought to break the pattern of self-
serving interests in public hospitals and reform the management system. The
separation of management and surveillance involves distinguishing the functions
of surveillance and management, ensuring actual ownership after separation, and
realizing the efficient management of public hospitals. There are two main patterns
of separation: first, separation between management and surveillance under the
same organization. An example of such a separation would be the creation of an
investor representative agency that operated within the framework of the Health
Bureau; clarified the functions of surveillance organizations for public hospitals in
the Health Bureau; and fulfilled the responsibilities of both management and
Another random document with
no related content on Scribd:
guide a tool. The slide-rest, while it had been invented, had not been
put into practical form or come into general use. There were a few
rude drilling and boring machines, but no planing machines, either
for metal or wood. The tool equipment of the machinist, or
“millwright,” as he was called, consisted chiefly of a hammer, chisel
and file. The only measuring devices were calipers and a wooden
rule, with occasional reference perhaps to “the thickness of an old
shilling,” as above. Hand forging was probably as good as or better
than that of today. Foundry work had come up to at least the needs
of the time. But the appliances for cutting metal were little better than
those of the Middle Ages.
Such was the mechanical equipment in 1775; practically what it
had been for generations. By 1850 it was substantially that of today.
In fact, most of this change came in one generation, from about 1800
to 1840. Since that time there have been many improvements and
refinements, but the general principles remain little changed. With so
wonderful a transformation in so short a time, several questions arise
almost inevitably: Where did this development take place, who
brought it about, and why was it so rapid?
The first question is fairly simple. England and America produced
the modern machine tool. In the period mentioned, England
developed most of the general machine tools of the present day; the
boring machine, engine lathe, planer, shaper, the steam hammer and
standard taps and dies. Somewhat later, but partially coincident with
this, America developed the special machine tool, the drop hammer,
automatic lathes, the widespread commercial use of limit gauges,
and the interchangeable system of manufacture.
In a generalization such as this, the broad lines of influence must
be given the chief consideration. Some of the most valuable general
tools, such as the universal miller and the grinder, and parts of the
standard tools, as the apron in the lathe, are of American origin. But,
with all allowances, most of the general machine tools were
developed in England and spread from there throughout the world
either by utilization of their design or by actual sale. On the other
hand, the interchangeable system of manufacture, in a well-
developed form, was in operation in England in the manufacture of
ships’ blocks at Portsmouth shortly after 1800; and yet this block-
making machinery had been running for two generations with little or
no influence on the general manufacturing of the country, when
England, in 1855, imported from America the Enfield gun machinery
and adopted what they themselves styled the “American”
interchangeable system of gun making.[7]
[7] See page 139.

The second question as to who brought this change about is not

so simple. It is not easy to assign the credit of an invention. Mere
priority of suggestion or even of experiment seems hardly sufficient.
Nearly every great improvement has been invented independently by
a number of men, sometimes almost simultaneously, but often in
widely separated times and places. Of these, the man who made it a
success is usually found to have united to the element of invention a
superior mechanical skill. He is the one who first embodied the
invention in such proportions and mechanical design as to make it
commercially available, and from him its permanent influence
spreads. The chief credit is due to him because he impressed it on
the world. Some examples may illustrate this point.
Leonardo da Vinci in the fifteenth century anticipated many of the
modern tools.[8] His sketches are fascinating and show a wonderful
and fertile ingenuity, but, while we wonder, we smile at their
proportions. Had not a later generation of mechanics arisen to re-
invent and re-design these tools, mechanical engineering would still
be as unknown as when he died.
[8] American Machinist, Vol. 32, Part 2, pp. 821 and 868.

Take the slide-rest. It is clearly shown in the French encyclopedia

of 1772, see Fig. 3, and even in an edition of 1717. Bramah,
Bentham and Brunel, in England, and Sylvanus Brown,[9] in America,
are all said to have invented it. David Wilkinson, of Pawtucket, R. I.,
was granted a patent for it in 1798.[10] But the invention has been,
and will always be, credited to Henry Maudslay, of London. It is right
that it should be, for he first designed and built it properly, developed
its possibilities, and made it generally useful. The modern slide-rest
is a lineal descendant from his.
[9] Goodrich: “History of Pawtucket,” pp. 47-48. Pawtucket, 1876.
 [10] Ibid., p. 51.

Blanchard was by no means the first to turn irregular forms on a

lathe. The old French rose engine lathe, shown in Fig. 4, embodied
the idea, but Blanchard accomplished it in a way more mechanical,
of a far wider range of usefulness, and his machine is in general use
to this day.
Figure 3. French Slide-Rest, 1772
 Figure 4. French Lathe for Turning Ovals, 1772

The spindle swings sidewise under the influence of the two cams which bear
against the upright stops
 JOSEPH BRAMAH Sir SAMUEL Sir MARC I.
1748-1814 BENTHAM BRUNEL
Invented Lock, Hydraulic 1757-1831 1769-1849
press, 4-way cock, and 44 NEW MACHINES.
wood working machinery. BLOCK M’CHRY-1800-08
HENRY MAUDSLAY
1771-1831
 Slide rest for metal work, Block machinery, Flour,
Sawmill and Mint mach’ry, Punches, Mill and Marine
Steam Engines, Fine screw cutting. Laid basis for
Lathe, Planer and Slotter
JOSEPH CLEMENT
1779-1844
Slide Lathe, Planer 1820 and 1824
Manufactured Taps and Dies Standard
Screw Threads
MATT. JAMES RICH’D. JOSEPH JAMES
MURRAY FOX ROBERTS WHITWORTH NASMYTH
1803-87 1808-90
Engines D- Index Versatile Std. Screw Index
Valve Cutting of Inventor, Threads Milling
Planer Gears Planer Foremost tool Shaper
Lathes, builder of the Steam
Planer 19th Century Hammer
Am. Machinist

Figure 5. Genealogy of the Early English Tool Builders

To the third question as to why this development when once begun

should have been so rapid, there are probably two answers. First, an
entirely new demand for accurate tools arose during these years,
springing from the inventions of Arkwright, Whitney, Watt, Fulton,
Stephenson and others. The textile industries, the steam engine,
railways, and the scores of industries they called into being, all called
for better and stronger means of production. While the rapidity of the
development was due partly to the pressure of this demand, a
second element, that of cumulative experience, was present, and
can be clearly traced. Wilkinson was somewhat of an exception, as
he was primarily an iron master and not a tool builder, so his
relationship to other tool builders is not so direct or clear. But the
connection between Bramah, Maudslay, Clement, Whitworth and
Nasmyth, is shown in the “genealogical” table in Fig. 5.
Bramah had a shop in London where, for many years, he
manufactured locks and built hydraulic machinery and woodworking
tools. Maudslay, probably the finest mechanician of his day, went to
work for Bramah when only eighteen years old and became his
foreman in less than a year. He left after a few years and started in
for himself, later taking Field into partnership, and Maudslay &
Field’s became one of the most famous shops in the world.
Sir Samuel Bentham, who was inspector general of the British
navy, began the design of a set of machines for manufacturing pulley
blocks at the Portsmouth navy yard. He soon met Marc Isambard
Brunel, a brilliant young Royalist officer, who had been driven out of
France during the Revolution, and had started working on block
machinery through a conversation held at Alexander Hamilton’s
dinner table while in America a few years before. Bentham saw the
superiority of Brunel’s plans, substituted them for his own, and
commissioned him to go ahead.
In his search for someone to build the machinery, Brunel was
referred to Maudslay, then just starting in for himself. Maudslay built
the machines, forty-four in all, and they were a brilliant success.
There has been considerable controversy as to whether Bentham or
Brunel designed them. While Maudslay’s skill appears in the
practical details, the general scheme was undoubtedly Brunel’s. In a
few of the machines Bentham’s designs seem to have been used,
but he was able enough and generous enough to set aside most of
his own designs for the better ones of Brunel.
Of the earlier tool builders, Maudslay was the greatest. He, more
than any other, developed the slide-rest and he laid the basis for the
lathe, planer and slotter. His powerful personality is brought out in
Nasmyth’s autobiography written many years later. Nasmyth was a
young boy, eager, with rare mechanical skill and one ambition, to go
to London and work for the great Mr. Maudslay. He tells of their
meeting, of the interest aroused in the older man, and of his being
taken into Maudslay’s personal office to work beside him. It is a
pleasing picture, the young man and the older one, two of the best
mechanics in all England, working side by side, equally proud of
each other.
Joseph Clement came to London and worked for Bramah as chief
draftsman and as superintendent of his works. After Bramah’s death
he went to Maudslay’s and later went into business for himself. He
was an exquisite draftsman, a fertile inventor, and had a very
important part in the development of the screw-cutting lathe and
planer. Joseph Whitworth, the most influential tool builder of the
nineteenth century, worked for Maudslay and for Clement and took
up their work at the point where they left off. Under his influence
machine tools were given a strength and precision which they had
never had before. Richard Roberts was another pupil of Maudslay’s
whose influence, though important, was not so great as that of the
others.
We have an excellent example of what this succession meant.
Nasmyth tells of the beautiful set of taps and dies which Maudslay
made for his own use, and that he standardized the screw-thread
practice of his own shop. Clement carried this further. He established
a definite number of threads per inch for each size, extended the
standardization of threads, and began the regular manufacture of
dies and taps. He fluted the taps by means of milling cutters and
made them with small shanks, so that they might drop through the
tapped hole. Whitworth, taking up Clement’s work, standardized the
screw threads for all England and brought order out of chaos.
Some account of the growth of machine tools in the hands of
these men will be given later. Enough has been said here to show
the cumulative effect of their experience, and its part in the industrial
advance of the first half of the nineteenth century. Similar
successions of American mechanics will be shown later.
Writing from the standpoint of fifty years ago, Smiles quotes Sir
William Fairbairn: “‘The mechanical operations of the present day
could not have been accomplished at any cost thirty years ago; and
what was then considered impossible is now performed with an
exactitude that never fails to accomplish the end in view.’ For this we
are mainly indebted to the almost creative power of modern machine
tools, and the facilities which they present for the production and
reproduction of other machines.”[11]
[11] Smiles: “Industrial Biography,” p. 399.
 CHAPTER II
WILKINSON AND BRAMAH
In the previous chapter it was stated that John Wilkinson, of
Bersham, made the steam engine commercially possible by first
boring Watt’s cylinders with the degree of accuracy necessary, and
that his boring machine was probably the first metal-cutting tool
capable of doing large work with anything like modern accuracy.
Although Wilkinson was not primarily a tool builder but an iron
master, this achievement alone is sufficient to make him interesting
to the tool builders of today.
He was born in 1728. His father made his financial start by
manufacturing a crimping iron for ironing the fancy ruffles of the day.
John Wilkinson first started a blast furnace at Belston and later
joined his father in an iron works the latter had built at Bersham, near
Chester. By developing a method of smelting and puddling iron with
coal instead of wood-charcoal, he obtained an immense commercial
advantage over his rivals and soon became a powerful factor in the
iron industry. Later, he built other works, notably one at Broseley,
near Coalbrookdale on the Severn.
One of the important branches of his work was the casting and
finishing of cannon. It was in connection with this that he invented
the boring machine referred to. He bored the first cylinder for Boulton
& Watt in 1775. Farey, in his “History of the Steam Engine,” says:
In the old method, the borer for cutting the metal was not guided in its
progress,[12] and therefore followed the incorrect form given to the cylinder in
casting it; it was scarcely insured that every part of the cylinder should be circular;
and there was no certainty that the cylinder would be straight. This method was
thought sufficient for old engines; but Mr. Watt’s engines required greater
precision.
[12] See Fig. 1.
 Mr. Wilkinson’s machine, which is now the common boring-machine, has a
straight central bar of great strength, which occupies the central axis of the
cylinder, during the operation of boring; and the borer, or cutting instrument, is
accurately fitted to slide along this bar, which, being made perfectly straight,
serves as a sort of ruler, to give a rectilinear direction to the borer in its progress,
so as to produce a cylinder equally straight in the length, and circular in the
circumference. This method insures all the accuracy the subject is capable of; for if
the cylinder is cast ever so crooked, the machine will bore it straight and true,
provided there is metal enough to form the required cylinder by cutting away the
superfluities.[13]
[13] Farey: “Treatise on the Steam Engine,” p. 326. 1827.

Wilkinson’s relations with Boulton & Watt became very intimate.

He showed his confidence in the new engine by ordering the first
one built at Soho to blow the bellows of his iron works at Broseley.
Great interest was felt in the success of this engine. Other iron
manufacturers suspended their building operations to see what the
engine could do and Watt himself superintended every detail of its
construction and erection. Before it was finished Boulton wrote to
Watt:
Pray tell Mr. Wilkinson to get a dozen cylinders cast and bored from 12 to 50
inches in diameter, and as many condensers of suitable sizes; the latter must be
sent here, as we will keep them ready fitted up, and then an engine can be turned
out of hand in two or three weeks. I have fixed my mind upon making from 12 to 15
reciprocating, and 50 rotative engines per annum.[14]
[14] Smiles: “Boulton & Watt,” p. 185. London, 1904.

This letter is interesting as showing Boulton’s clear grasp of the

principles of manufacturing. Later, when Boulton & Watt were hard
pressed financially, Wilkinson took a considerable share in their
business and when the rotative engine was developed he ordered
the first one. He consequently has the honor of being the purchaser
of the first reciprocating and the first rotary engine turned out by
Watt. Later, when Watt was educating his son to take up his work, he
sent him for a year to Wilkinson’s iron works at Bersham, to learn
their methods.
Fig. 7, taken from an old encyclopedia of manufacturing and
engineering, shows the boring machine used for boring Watt’s steam
cylinders.
 On two oaken stringers SS, frames FF were mounted which
carried a hollow boring bar A driven from the end. The cylinder to be
bored was clamped to saddles, as shown. The cutters were carried
on a head which rotated with the bar and was fed along it by means
of an internal feed-rod and rack. In the machine shown the feeding
was done by a weight and lever which actuated a pinion gearing with
the rack R, but later a positive feed, through a train of gears
operated by the main boring-bar, was used. Two roughing cuts and a
finishing cut were used, and the average feed is given as ¹⁄₁₆ inch
per revolution. While this machine may seem crude, a comparison
with Smeaton’s boring machine, Fig. 1, will show how great an
advance it was over the best which preceded it.
Wilkinson was a pioneer in many lines. He built and launched the
first iron vessel and in a letter dated July 14, 1787, says:
Yesterday week my iron boat was launched. It answers all my expectations, and
has convinced the unbelievers who were 999 in a thousand. It will be only a nine
days wonder, and then be like Columbus’s egg.[15]
[15] “Beiträge zur Geschichte der Technik und Industrie,” 3. Band. S.
227. Berlin, 1911.

In another letter written a little over a year later, he says:

There have been launched two Iron Vessels in my service since Sept. 1st: one is
a canal boat for this [i.e., Birmingham] navigation, the other a barge of 40 tons for
the River Severn. The last was floated on Monday and is, I expect, at Stourport
with a loading of bar iron. My clerk at Broseley advises me that she swims
remarkably light and exceeds my expectations.[16]
[16] Ibid., 3. Band. S. 227.

In 1788 William Symington built and ran a steam-operated boat on

Dalswinton Loch in Scotland, which was a small, light craft with two
hulls, made of tinned sheet-iron plates.[17] It has been erroneously
claimed that this was the first iron boat. It was at best the second.
Although of no commercial importance, it is of very great historical
interest as it antedated Fulton’s “Clermont” by many years.
[17] Autobiography of James Nasmyth, p. 30. London, 1883.
 Twenty-three years later, in 1810, Onions & Son of Broseley built
the next iron boats, also for use upon the Severn. Five years later
Mr. Jervons of Liverpool built a small iron boat for use on the Mersey.
In 1821 an iron vessel was built at the Horsley works in
Staffordshire, which sailed from London to Havre and went up the
Seine to Paris.[18] Iron vessels were built from time to time after that,
but it was fully twenty-five years before they came into general use.
[18] Smiles: “Men of Invention and Industry,” pp. 51-52. New York, 1885.
Figure 6. John Wilkinson
 Figure 7. Wilkinson’s Boring Machine

Used for Machining the Cylinders of Watt Engines

With Abraham Darby, 3d, Wilkinson has the honor of having built,
in 1779, the first iron bridge, which spanned the Severn at Broseley.
This bridge had a span of 100 feet 6 inches, and a clear height of 48
feet, and is standing today as good as ever.[19] He invented also the
method of making continuous lead pipe.
[19] Smiles: “Industrial Biography,” p. 119. Boston, 1864. Also, Beiträge,
etc., 3. Band. S. 226.

He was a man of great ability, strong and masterful. Boulton wrote

of him to Watt:
I can’t say but that I admire John Wilkinson for his decisive, clear, and distinct
character, which is, I think, a first-rate one of its kind.[20]
[20] Smiles: “Boulton & Watt,” p. 438. London, 1904.

There is a note of qualification in the last clause. With all his

admirable qualities Wilkinson was not always amiable and he was in
constant feud with the other members of his family. He became very
wealthy, but his large estate was dissipated in a famous lawsuit
between his heirs.
Forceful and able as Wilkinson was, another man, Joseph
Bramah, living in London about the same time, had a much more
direct influence on tool building. Bramah was a Yorkshire farmer’s
boy, born in 1748, and lame.[21] As he could not work on the farm he
learned the cabinet maker’s trade, went to London, and, in the
course of his work which took him into the well-to-do houses about
town, he made his first successful invention—the modern water-
closet. He patented it in 1778 and 1783, and it continues to this day
in substantially the same form. In 1784 he patented a lock, which
was an improvement on Barron’s, invented ten years before, and
was one of the most successful ever invented. For many years it had
the reputation of being absolutely unpickable. Confident of this,
Bramah placed a large padlock on a board in his shop window in
Piccadilly and posted beneath it the following notice:
“The artist who can make an instrument that will pick or open this lock shall
receive two hundred guineas the moment it is produced.”
[21] The best account of Bramah is given in Smiles’ “Industrial
Biography,” pp. 228-244. Boston, 1864.

Many tried to open it. In one attempt made in 1817, a clever

mechanic named Russell spent a week on it and gave it up in
despair. In 1851 Alfred C. Hobbs, an American, mastered it and won
the money. He was allowed a month in which to work and the
Committee of Referees in their report stated that he spent sixteen
days, and an actual working time of fifty-one hours, in doing it. This
gave Hobbs a great reputation, which he enhanced by picking every
other lock well known in England at that time, and then showing how
it was done.
This started up the liveliest kind of a controversy and gave
everyone a chance to write to the Times. They all began first picking,
then tearing each other’s locks. Headlines of “Love (Hobbs?) Laughs
at Locksmiths,” “Equivocator” and other like terms appeared.[22]
[22] Price: “Fire and Thief-proof Depositories, and Locks and Keys.”

It was finally recognized that any lock could be picked by a skillful

mechanic with a knowledge of locks, if he were given time enough.
The old Bramah lock, made, by the way, by Henry Maudslay himself,
did not fare so badly. Hobbs had unmolested access to it for days
with any tools he could bring or devise; and though he finally opened
it, a lock probably sixty years old which could stand such an assault
for fifty hours was secure for all ordinary purposes.[23]
[23] Anyone who is interested can find an account of the affair in Price’s
“Fire and Thief-proof Depositories, and Locks and Keys,” published in 1856,
and Mr. Hobbs has given his own personal account of it, explaining how the
work was done, in the Trans. of the A. S. M. E., Vol. VI, pp. 248-253.

When Bramah began manufacturing the locks he found almost

immediately that they called for a better quality of workmanship than
was available, with even the best manual skill about him. A series of
machine tools had to be devised if they were to be made in the
quantities and of the quality desired. He turned first to an old
German in Moodie’s shop who had the reputation of being the most
ingenious workman in London; but while he, with Bramah, saw the
need, he could not meet it. One of his shopmates, however,
suggested a young man at the Woolwich Arsenal named Henry
Maudslay, then only eighteen years old.
Bramah sent for him and Maudslay soon became his right-hand
man, and was made superintendent of the works at nineteen. The
work of these two men in developing the tools needed laid the
foundation for the standard metal-cutting tools of today. The most
important improvement was the slide-rest. Nasmyth later said that he
had seen the first one, made by Maudslay, running in Bramah’s shop
and that “in it were all those arrangements which are to be found in
the most modern slide-rest of our own day” (i.e., fifty years later).
Other parts of the metal-cutting lathe also began to take shape; it
has been said that parts of the lock were milled on a lathe with rotary
cutters, and that the beginnings of the planer were made. How much
of this work was Bramah’s and how much Maudslay’s it would be
hard to say. Bramah was a fertile, clever inventor; but Maudslay was
the better general mechanic, had a surer judgment and a greater
influence on subsequent tool design.
About this time Bramah invented the hydraulic press. As he first
built it, the ram was packed with a stuffing-box and gland. This
gripped the ram, retarded the return stroke, and gave him a lot of
trouble until Maudslay substituted the self-tightening cup-leather
packing for the stuffing-box, an improvement which made the device
a success.
 Bramah’s restless ingenuity was continually at work. He invented a
very successful beer-pump in 1797, the four-way cock, a quill
sharpener which was in general use until quills were superseded by
steel pens, and he dabbled with the steam engine. He was a bitter
opponent of Watt and testified against him in the famous suit of
Boulton & Watt against Hornblower. He maintained the superiority of
the old Newcomen engines and said that the principle of the
separate condenser was fallacious, that Watt had added nothing
new which was not worthless, and that his so-called improvements
were “monstrous stupidity.”
In 1802 Bramah obtained a patent for woodworking machinery
second only in importance to that granted Bentham in 1791. Like
Bentham, he aimed to replace manual labor “for producing straight,
smooth, and parallel surfaces on wood and other materials requiring
truth, in a manner much more expeditious and perfect than can be
performed by the use of axes, saws, planes, and other cutting
instruments used by hand in the ordinary way.” His tools were
carried in fixed frames and driven by machinery. In his planing
machine, one of which was running in the Woolwich Arsenal for fifty
years, the cutter-head, which carried twenty-eight tools, was
mounted on a vertical shaft and swept across the work in a
horizontal plane. He used this same method in planing the metal
parts for his locks, which corresponds, of course, to our modern
face-milling. He provided for cutting spherical and concave surfaces
and used his device for making wooden bowls.
In 1806 he devised an automatic machine which the Bank of
England used many years in numbering their banknotes, eliminating
error and saving the labor of many clerks.
Maudslay was in his employ from 1789 to 1797. He was getting as
superintendent 30s. ($7.50) a week. A growing family and “the high
cost of living” rendered this insufficient and he applied for more. He
was refused so curtly that he gave up his position and started in for
himself in a small workshop on Oxford Street in London. Later he
took Field in as partner under the firm name of Maudslay & Field.
In 1813 Bramah engaged another man who later had a great
influence, Joseph Clement. Clement soon became his chief
draftsman and superintendent. Salaries had gone up somewhat by