GREAT BRITAIN

The impressive achievements of the British National Health Service stem from the firm commitment by government to accept responsibility for providing health care of high quality to all citizens without regard to their ability to pay. In 1946, the National Health Services Act was passed and in July, 1948, the NHS was launched amid naive prophecies, both for success and for failure. Today, after over 23 years of slow, evolutionary change, it stands as an impressive national achievement and a major source of national pride.

Health care has effectively been removed from the vagaries and inequities of the market place. Faced with the same awesome cost implications of modern advances in medicine and medical technology as other developed nations, this underlying social equity has become an even more prominent hallmark of national achievement than was ever imagined by those responsible for the original enabling legislation.

It has recently been estimated that less than 2% of health care is provided outside the NHS. Thus, the NHS plays a central and dominant role in health care delivery and financing. Almost 80% of its funds are derived from general revenues of government. The rest comes from a payroll tax, from local taxes based on real estate and from direct payments by patients for services.

The best in modern medicine is provided to all citizens with virtually no direct payment for important services. (The last Labour government reintroduced a small deterrent charge for prescription drugs, but this is waived for all populations groups to whom this might be an onerous burden.)

The total cost of health care provision in the United Kingdom is both of interest and relevance to the current national debate on the health crisis in America. In the United Kingdom the total expenditures of health services in 1970 was of the order of 1,800 million pounds. If this figure is multiplied by 10 to convert to U.S. dollars and to correct for the disparity in population size, the $18 billion total fails to reflect differences in wealth and standards of living. However, if this amount is further multiplied by a factor which represents the ratio between the American and the United Kingdom per capita GNP, one arrives at a total of $41 billion, an amount substantially less than the sum of over $70 billion spent on health care in the United States in 1970. These figures strongly suggest that with appropriate reform of the delivery system in the United States, a much more equitable distribution of health services of higher quality can be achieved at substantial cost savings.

From the vantage point of an American perspective, another striking lesson to be learned from the National Health Service is the cost of saving and the quality improvement which flow from their system of primary care provision. The general practitioner service provides virtually every man, woman, and child in the United Kingdom with a family physician who is able competently to manage over 95% of the real or imagined ills of his patient. For those who require specialist attention, the general practitioner is able to guide them into the complex maze of modern hospital medicine and into the hands of the appropriate hospital-based specialist. Throughout, the patient has no

This system is structured to take advantage of a remarkable degree of freedom. Contrary to misleading myth, patients have free choice of a general practitioner (within reasonable geographic limits), and in turn, the general practitioner can exercise his right to accept or reject an application for a new patient to join his "list."

Each of the 22,000 general practitioners has an average of 2,450 patients. This average is exceeded in the more sparsely doctored areas, but even there the average is seldom significantly more than 3,000 patients. (In 1965, the General Medical Services Committee of the British Medical Association recommended ultimately an average of the order of 2,000 patients per general practitioner as an ideal to aim at.)

As a matter of national policy, the general practitioner service has received special attention from successive governments. The rational organization of health manpower has been buttressed by the general practitioner service. Rightfully, general practitioners are considered the bedrock of the system and access to specialists in the National Health Service can only be gained on referral from a general practi tioner.

In contrast, this rational and efficient division of labor between generalists and specialists in the United States is essentially non-existent. Here the declining number of generalists and the sometimes ludicrous proliferation of specialists has, in many areas of the United States, made general practitioners a dying breed. The functional maldistribution of medical manpower, together with the absolute shortage physicians, has had appalling consequences both in terms of cost and quality of health care.

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In the United Kingdom, unlike the United States, the specialist is unencumbered with the comparative trivia of minor complaints dealt with more appropriately by the primary care provider. In addition. he is spared much of the task of managing the broader and more complicated problems of his patients' physical, social and psychological adjustment, problems for which he is untrained to cope as success fully as is his colleague in general practice. For this reason, the British manage with fewer neurosurgeons serving their population of 50 million than there are at present in the city of San Francisco. Similarly, two pediatricians suffice in Oxford, which had a 1968 population of 110,000, while New Haven, Connecticut, has about 30 pediatricians serving its 1970 population of approximately 134,000. To quote Walter McNerney in describing the National Health Service, "Nominal needs are spared the costly reflexes of the Consultant (specialist)."

Again in contrast to the United States, the public attitude toward the National Health Service in general, and toward their general practitioners in particular, is enthusiastically approving. Nearly everyone can name their general practitioner, which stands in bold contrast to the situation in the United States. Here the number of general practitioners is rapidly declining and, because of the age distribution of those who remain, the further precipitous decline in their numbers in the immediate future is inevitable even if there is a heavy infusion of funds and other incentives to encourage recruitment among young medical graduates.

Of the approximately 2 billion pounds spent on National Health and Welfare Services in 1970, the general practitioner services absorbed only about 8% of this total. Hospitals accounted for approxi

mately 60% of expenditure, public health and welfare required approximately 15%, drugs about 10%, dental care about 5% and central administration 0.6%.

The cost of the National Health Service is even more worthy of analysis by Americans when one considers the efficiency of the British system in utilizing resources. While the NHS can be justly praised for its underlying equity and for the generally high standard of quality of care provided, on this issue of efficiency it must receive a comparatively poor rating. The basis for this critical judgment is well documented in the "Digest of Health Statistics for England and Wales-1970" prepared by the Department of Health and Social Security. In 1968, the last year for which figures are currently available, the through-put (cases per available bed) in acute general hospitals ranged from a high of 30.1 in the Oxford region to a low of 20.0 in the Liverpool area. This disparity is reflected in the average length of stay in such acute general hospital beds, varying from 9.4 days in the Oxford region to 14 days in Liverpool.

Another great achievement of the NHS has been its very positive impact in improving the geographic distribution of high quality specialist services. These tended to be concentrated in the London area, in Edinburgh, and other centers of medical excellence. The National Health Service has effected a radical change in the direction of a more rational and equitable distribution throughout the country. Here the power of central decision making has been used to good effect.

Even more impressive to me than the very considerable and general sense of national pride evoked by mention of the NHS in Britain is the attitude of British doctors toward the Health Service. Contrary to myths which have been so freely circulated in the United States for factional advantage and self-interest, British doctors were found to be largely supportive of the NHS and proud of both the equity of the system and the quality of care they provide within it. Through their democratically organized British Medical Association, which represents all factions and special interests among British doctors, they have a continuing and generally amicable consultative working relationship with government. In this system, as in any other comprehensive system of health services, such cooperation from the medical profession is essential not only in insuring that the system works, but also in providing the necessary pressure for responsiveness to change and informed direction to progressive reform.

At the same time the doctors are obviously cognizant of their dependence on the government for funds and their relationship with government has not always been entirely happy. In the mid 1960's, for example, there was a brief interlude when many general practitioners were almost in open revolt over remuneration and other conditions of service. At one point, 17,000 had submitted their resignations from the NHS to their representatives in the BMA to be used as a bargaining chip with the government. By adroit negotiation the crisis was averted and government moved a long way in the direction of meeting the demands of the general practitioners. This example of open hostility between government and the medical profession is the sort of exception that proves the rule. Generally, the profession bears a cooperative and supportive attitude toward government. This attitude

profession in the BMA but by many members of the rank and file whose opinions were assiduously sought. It is also noteworthy that the leadership of the Junior Hospital Doctors Association, the only significant splinter group which is seeking to obtain separate negotiating rights for junior hospital doctors (interns and residents), were generally supportive of the underlying principles of the NHS. In spite of the many real and serious grievances which these young specialists-intraining expressed regarding their conditions of service and career prospects, none expressed a desire to return to a free market system of health care provision. Like young people elsewhere, they proved more adept at describing problems than proposing solutions. While alarmed at the annual emigration rate among British doctors, they themselves vehemently support the underlying equity of the system in treating patients. They themselves don't want to emigrate. They want to stay and make the system work.

I was enormously impressed with how much has been done, with comparatively meager resources, to improve the quality of life for the elderly and those suffering from chronic illness. While the British seem dissatisfied with their present level of achievement, the standard of care provided for these patients and the imaginative innovations in their management stand in striking contrast to the common neglect and nihilism which growing numbers of elderly and chronic sick face in the United States. The Subcommittee obtained impressive firsthand evidence of the enormous benefit which can accrue to this disad vantaged segment of the population from the effort of intelligently interested professionals, who work together as a team, to improve the quality of care and the quality of life for both the patients and their families.

In striking contrast to the United States, where there is an enor mous gap between the acute general hospital and the custodial dumping ground of the public nursing home and its expensive private counterpart, (which may be a bit more comfortable and less unat tractive, but which is not much less depressing nor significantly more successful in achieving rehabilitation), in Britain I saw the egalitarian principle underlying the National Health Service at its best. At impressively low cost, they have implemented dynamic programs for care and rehabilitation for the elderly. The central objective is to maintain them as functioning members of society as long as possible in their homes rather than to incarcerate them in depressing custodial

institutions.

This is achieved by accurate initial assessment and frequent periodic professional review of their status and potential in pleasant, cheerful. but simple accommodation in active geriatric units. Progressive nurs ing care is applied in these units in conjunction with vigorous efforts in rehabilitation and training in self-help. This leads to early discharge, but contact is not lost. The patients are not thrown out to fend for themselves or to burden unduly the resources and patience of their families. Periodic review is maintained on an out-patient basis and an impressive array of home services is provided. These include home nursing services, mental health services, visiting physiother apists and occupational therapists, home help services, meals-on-wheels and a variety of other aids to maintain the patient as independently as possible for as long as possible in the home environment.

The more impressive of these programs clearly demonstrate effective collaboration among the three branches of the NHS at the local level. In addition, the team effort includes a heavy commitment from voluntary agencies. The latter include a wide range of activities such as "friendly visiting," social clubs, workshops, group holidays, day care schools, assistance from non-profit building societies and Red Cross loan schemes. It has frequently been claimed that provision of comprehensive health services organized and financed by government effectively kills voluntary effort and private initiative. Perhaps it can. In this sector of the NHS, however, I found impressive evidence of the vitality and value of service by a broad spectrum of voluntary agencies working in close and effective cooperation with government. In summary, I received overwhelming evidence to demonstrate the value of government commitment to provide health care of high quality to all its citizens. The NHS is certainly not perfect, but it has effectively achieved a large measure of social justice in an area where the United States, for all its wealth and power, has failed so far to recognize good health care as a matter of right. The British provide this service at substantially less cost per capita than we do and they enjoy the cooperative support of the doctors, dentists, nurses, and countless other health professionals who serve in the front lines of health care delivery.

The NHS stands as an impressive jewel in the crown of national pride. We should accept its underlying philosophy and give effect to this commitment in a form appropriate to our own national history and our present needs and resources. The whole system deserves our careful study. I believe we have much to learn from it.

ISRAEL

I came to Israel with my colleagues on the Senate Health Subcommittee, from the richest nation in the world with the most impressive medical and research facilities, to see how Israel handled its health care problems. For the United States is caught in the midst of a massive health crisis, and we were looking for clues to possible solutions. Not only is America no longer the world's foremost purveyor of medical care, it has, in fact, slid to 22d place on the list of countries whose male citizens have a high life expectancy (10th place for females).

Our medical crisis, which seems to grow worse from year to year, has disturbed me as a Senator, and it has spurred many of my colleagues in Congress to search for a solution. Other countries have wrestled with the question of providing economic and high quality medical care for their citizens, regardless of income or social status, and some of them have worked out elaborate national health care systems.

What impressed me most was the vast philosophical differences between the nations we visited and the United States regarding the citizen's right to decent health care. Again and again, I was struck by the contrast between societies which place health first and dollars second and our own, in which purchasing power must precede the provision of medical care.

America's medical emergency has been brought on by four interrelated elements, and I kept these factors in mind as I talked with