In none of the countries I visited was it necessary for the people to face the hazard of financial ruin because of illness. Indeed, in most of the countries we visited, financial protection against illness was available on a completely uniform basis for all. In Sweden, for example, the patient pays only 7 crowns-about $1.40-to see the doctor, and 10 crowns-about $2.00-for any hospitalization. The remainder is paid by government insurance. There is a uniform benefit package for every citizen and non-citizen resident. Benefits are unrelated to sex, employment status, race, income or social position. A similar arrangement exists in Norway, Denmark, and Finland, and the same is true of England.

In Israel, health care is financed through a variety of mechanisms, but evident throughout is a philosophical commitment to comprehensive health care first and ability to pay second. What a sharp contrast that is to the situation in the United States. Here, we are trapped in a patchwork quilt of health insurance plans, sold by over 1,100 different health insurance companies. There are enormous variations in the cost and benefit packages, and the profits are unconscionable.

We know the frustrations of health insurance in America. We know it comes in hundreds of different packages, based on age, income, employment status, past health record, and a dozen of other factors unrelated to the need for care. In America, the health needs of the people always finish second. The primary concern is cost and the health of the industry balance sheet.

How can a credit rating be more important than emergency treatment for illness? Why can England, Israel, Denmark and Sweden protect their people against financial barriers to health care, when America cannot? How can these European countries afford to make health care a basic right for their people, when the wealthiest nation in the world cannot?

In Sweden I visited the town of Kiruna, which rests among snowcapped mountains 150 miles above the Arctic Circle. I saw workers in the iron mines, proud of the excellent system of health care for themselves and their families. Compare those mine workers, 150 miles above the Arctic Circle in Sweden, with the mine workers I saw in Kingwood, West Virginia, which is 150 miles from the nation's capital. In Kingwood, they can't even find a doctor in an emergency, let alone provide the continuing care they need. We saw such contrasts repeated everywhere we went. And gradually we began to realize the devastating indictment they bring to health care in America. It is a serious and tragic failure of our society-a failure which all Americans share. The third major lesson we learned in Europe was that medical care can be well organized. It can be rationalized.

In our investigation of the health care crisis in America, we saw repeated examples of waste and inefficiency in the way valuable material and human resources are spent.

We saw a beautiful new hospital in West Virginia, constructed with Hill-Burton funds. We found an entire wing padlocked and empty. The hospital's occupancy rate was only 25% because there are only three doctors in the entire county to staff it.

In city after city in America, in areas like kidney transplants, openheart surgery, neurosurgery, and radiation therapy, new and expensive

They have been built at the expense of the public, but not because of need.

In Beverly Hills, California, there is a ratio of one doctor for every 80 residents. In Venice, California, 15 miles and 2 hours away by public transportation, the ratio is one doctor for every 1600 residents.

And costs go up and up. Per capita expenditures for personal health services in the nation have risen from $79 in 1950 to $324 in 1970. For this overall expenditure, every man, woman and child in the country could have two memberships in the Harvard Community Health Plan. These illustrations dramatize the inefficient and disorganized system of American health care. By contrast, the nations of Europe have succeeded, at least partially, in solving these problems of organization and delivery.

In Sweden, for example, a system of physician and hospital regionalization exists. Each local district has a health officer, a general prac titioner, and a small hospital, staffed by internists, surgeons, pediatricians and radiologists.

The local hospital relates intimately to the general practitioners and health stations in the area. For more complex cases, a regional hospital of intermediate size exists with facilities for long-term care, tation, and more sophisticated procedures.

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Each district hospital relates to a specific regional hospital. For still more sophisticated problems, each regional hospital relates to one of the five university teaching centers in Sweden, where treatment is by referral only. These hospitals, physicians and health centers are linked together by an effective network of transportation services. They use ambulances, airplanes, trains and ships-and all the services are cov ered under the national health care benefits.

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Why can Norway, Sweden, and Finland provide district health offi cers for Lapland, when we can't find doctors to serve the of Appalachia or the migrants on the Western Slopes of the Rockies! Why can the State of Israel place doctors in a family health care center to treat nomads in the desert, when the rural areas of America cry out for medical attention?

The answer is in the way we allocate health resources. In Europe, they have a mechanism for rational planning. They have the ability to implement that planning, and they have it in abundance. The ca pacity to formulate and implement public health policy is highly developed in the European countries we visited. That capacity is essentially nonexistent in the United States. Unless we are able to develop that ability, we will continue to spend a greater and greater share of our national wealth on health care, and we will continue to receive far less value for our money than in any of the nations we visited.

The fourth major lesson we learned was that the rational production and utilization of health manpower does not need to be a national

crisis.

Sweden, for example, intends to double its number of physicians in the next decade, simply by increasing the number of medical students. Each student receives his education at public expense, and he receives a subsistence allowance in addition, independent of his income or social position.

At the postgraduate level, all hospitals in Sweden are accredited teaching hospitals. They all have the Swedish equivalent of interns and residents-even in the most remote areas.

Surprising as it may seem, we met Danish and Norwegian physicians in Northern Sweden, drawn from the common Scandinavian medical labor market. Many of these physicians had stayed to practice in these remote areas, after receiving their training there.

In addition, the Board of Medicine in Stockholm controls the number of residency positions available in each specialty. It is thereby able to influence the number of specialists of each type. It influences the supply of general practitioners, according to national needs. In country after country, as these examples demonstrate, we saw evidence of a planning capability far superior to anything that presently exists in America.

In Beersheeba, in the Negev Desert in Israel, construction has begun on a new medical school. The school has been established by the main insurance funds of the Israel Labor Federation, in order to assure that rural physicians have access to a center of academic excellence. They hope that more physicians will be attracted to rural Israel because of this. The school will offer quality health care to Arab and Jew alike. In Denmark, the government is in the process of integrating medical services with other social services. In Copenhagen, a major effort is underway to construct housing facilities for the elderly. A publicly subsidized, privately owned, non-profit corporation is building the facilities. They will be constructed in neighborhoods where the elderly can have contact with the community and with young families.

The apartments are designed with an emphasis on the comfort, selfrespect and personal identity of the occupants. Residents are encouraged to furnish apartments with as many of their own belongings as possible.

Facilities are available for recreation, and the products of occupational therapy are offered for sale to the public. Most of the proceeds go to the person who made the object, thereby providing gainful employment in a very real sense for elderly people.

And so, these were the positive aspects of the European and Israeli health care systems we saw. I think you will agree that they hold important lessons for America. Lessons which, I believe, need to be promptly translated into legislation.

Senator EDWARD M. KENNEDY, Chairman, Senate Health Subcommittee.

HEALTH CARE IN GREAT BRITAIN

CHAPTER I

Introduction and Acknowledgments

The Health Subcommittee embarked on an intensive four and onehalf day study of health care in Britain on September 10th, 1971. The study was highly selective in that it concentrated on those aspects, both favourable and unfavourable, which are of special relevance to the health crisis in America. Of all of the countries visited during this fact-finding tour, the United Kingdom provided the closest parallels to the American experience and the most instructive contrasts in methods of organizing and financing health care.

The itinerary was carefully planned after detailed study of testimony delivered before the Subcommittee in earlier health crisis hearings in Washington and across the United States. Careful consideration was given to the many analyses of health care delivery in Britain and the advice of both British and American experts was sought in planning the itinerary.

An enormous volume of evidence was gathered during the tour. This evidence has since been the subject of extensive study and analysis and, where appropriate, supplementary information has been sought from authorities in the United Kingdom. These same authorities who had already given so generously of their time and expertise before and during the fact-finding investigation, continued to lend their support and help in gathering such supplementary information. Chapter II sets out a summary of the chief observations and conclusions arising out of the Subcommittee's study of health care delivery and financing in Britain.

Chapter III describes the National Health Service, its origins, how it is structured, administered and financed and the current plans for reform. In addition, certain specific issues of special relevance to the health crisis in the United States are considered in greater detail. These include remuneration of doctors and dentists; health manpower distribution; new hospital construction; and geriatric, convalescent and psychiatric care and care for the chronically ill.

Chapter IV is devoted to analysis of the private sector, whose total impact is more significant than the amount of money which is spent within it would suggest.

Chapter V describes the Subcommittee itinerary in Britain and includes additional information and impressions gleaned from the interviews and studies of the Subcommittee during the four and one-half day visit.