be "as much as 12% of total NHS remuneration for all medical and professional staff and to an even significantly higher proportion compared to NHS payments to the consultant staff alone.

"The character and function of the private sector spending on medi cal care can be brought out more clearly, however, when related to NHS and private sector costs per person. In its broadest sense, the NHS represented a comprehensive health insurance scheme for all. In 1968, NHS spending averaged some $80 per person, including $52.50 for hospital services of which $4 covered the hospital medical staff. The Provident population (those served by nonprofit insurers, about 1.9 million) in the same year spent an additional $18 per head, mainly for private hospital care of which $8.75 represented specialists' and consultants' fees."

What makes these figures really interesting is the size of the elective surgical waiting list within the NHS. The number now stands at just over 500,000 patients awaiting admission for elective surgery in England. In other words, about one person per hundred is "on the waiting list". In some parts of the country they then wait for possibly as long as five years for such services as repair of hernia, stripping of varicose veins, and certain elective orthopedic operations. Unless there is some urgent reason (or special pleading), patients are admitted in the order they were put on the list and must come into hospital when they are finally called.

The private sector in health care in the United Kingdom does more than satisfy a degree of private freedom within the most stable of liberal democracies. While small in size, it does impact with the public system in a wide variety of ways some of which are neither suscepti ble of precise measurement nor of crude estimate.

The Subcommittee was interested to note certain features of the private sector in the United Kingdom which are of special relevance to the health crisis in America. The non-profit "provident schemes" (among which BUPA, the British United Provident Association, is the giant) provide for over two-thirds of all payments for private medical care. They are roughly equivalent to the "Blues" in the United States, but there are important differences. They have a much more healthy arm's length relationship with the hospitals and doctors. The "Blues" do not have this arm's length relationship. Consistenly they have been at least as much concerned with payment to providers as they have been with service to subscribers.

Secondly, they have been imaginative and innovative in their response to the challenge of rising costs and have actively assisted in the provision of resources and personnel under efficient management to provide special facilities for multi-phasic screening and cervical

smears.

Thirdly, they have vigorously supported the rational functional relationship between generalists and specialists. Unlike their American counterparts, they do not pay for specialist services unless the patient has been referred by a primary care provider. Had the "Blues", and other private insurers, adopted and enforced this policy in the United States some of the present chaos in American medicine might have been averted. It is reasonable to suggest that the cost might be substantially less and the quality improved.

The a

CHAPTER V

The Subcommittee Itinerary

INTRODUCTION

The natural constraints associated with Congressional investigations in foreign countries effectively preclude verbatim reporting of interviews. Indeed, many of the persons who gave so freely of their knowledge and opinions in private would have been seriously inhibited by the possibility of direct quotation and hence the value of their individual contributions would have been markedly impaired. For this reason, better to serve the objectives of the Subcommittee study, such direct quotation is avoided except where opinions have already been expressed in public debate, in written material already in the public domain, or in written submission to the Subcommittee, either during the tour or in subsequent correspondence.

FRIDAY, SEPTEMBER 10, 1971

(1) The Northwick Park Hospital

This is an impressive new district general hospital. It is unique in the United Kingdom in that it combines the provision of a comprehensive array of acute general hospital services to the surrounding population of approximately 180,000 with a national center for clinical research. It has been planned and constructed as a joint project of the Northwest Metropolitan Regional Hospital Board and the Medical Research Council. "The proposal for a combined Hospital and Centre arose from a coincidence of plans: the Regional Board's wish to provide a much needed new district service in the Harrow and Wembley area, and a decision by the Medical Research Council that progress in the field of clinical research would best be encouraged by the coordination of the clinical, paraclinical and non-clinical sciences in one large centre."

Much of the hospital has been constructed and is now in use. The complex will be completed in 1973 by which time it will provide 790 beds, 180 of which will be allocated for clinical research.

The Subcommittee met first with key administrators, clinicians and clinical scientists who described the history and unique features of this imaginative joint venture. From an American perspective, the most noteworthy observation was the obvious ranking of priorities between patient care and clinical research. At Northwick Park patient care comes first. Yet the intimate structural, functional and organizational relationships between the facilities and staffs serving both principal objectives has been so organized that maximum advantage can be taken in the course of providing patient care of high quality for effectively meeting the needs of clinical research.

This order of priorities stands in bold contrast to the situation which obtains in many institutions devoted to clinical research in the United States where the patients' needs for care are considered secondary to the requirements for clinical research.

At Northwick Park a great measure of success has been achieved in creating a personal sense of identification with and pride in the hos pital among residents in the surrounding Boroughs of Brent, Harrow, and Ealing which it serves. Success in this effort was evidenced by the large number of people who provide volunteer services and by the attitude and enthusiasm of patients whom the Subcommittee met in the course of a tour of the wards and the outpatient department.

ad

The brochure describing the project (see Appendix X) sets out the benefits to be obtained from this joint venture, "There are many vantages to patients and to the community in this combination of research centre and hospital. Together they will be capable of providing care in illnesses which present special problems in diagnosis or treatment. The hospital and its patients will thus be on the threshold of advances in medical science and have access to the unique facilities of the research center, while the research workers will be in direct touch with the problems of disease as manifested in the community.

of

"The Board and the Hospital Management Committee are particu larly conscious of the fact that the 'district' task of the hospital can be achieved only as part of the larger task of the total health care the population in the area--a task involving a number of different authorities. To this end, the Board and the Management Committee have created a number of links with the community, particularly with the local health services, general practitioners, and voluntary orga nizations, and are working to strengthen these ties."

Both the architectural and organizational innovations in this dual purpose establishment are worthy of further analysis.

(2) The Chalkhill Health Centre, Wembley Park

This was the first of three Health Centres visited by the Health Subcommittee. It is situated in the new public (Local Authority) Chalkhill Housing Estate which houses 6,000 to 7,000 people. The Health Center was built by the London Borough of Brent with active encouragement and financial inducement from the Department of Health and Social Security. It was opened in September of 1970 and provides accommodation for 10 general practitioners who provide comprehensive primary medical care for about 18,000 people, most of whom live within a radius of 2-3 miles of the center.

The general practitioners retain their contractual relationships with the Executive Council, with their partners, and with their patients, What, in fact, is new is their practice accommodation, the facilities and personnel attached to it, and the opportunity this provides for im proved communication among them and with others who are involved in providing ambulatory care.

The premises were modern and attractive and the rapport among the staff and patients was obviously excellent.

The general practitioners see their patients on an appointment system. Patients can usually be seen on the same day as the request for an appointment.

The ten doctors work in four separate partnerships which had been established in the Wembley Park area for some time. The members of each partnership were known to one another because they had worked together on a rotation system for answering weekend calls. The doctors have access to out-patient, x-ray and other diagnostic services provided by nearby hospitals.

The Brent Health Department provides staff, including doctors, dentists, and health visitors who run ante-natal clinics, immunization clinics, well-baby clinics, birth control clinics and clinics for screening for cervical cancer.

Speech therapy services and audiometric services are also provided for children.

The Health Centre even includes facilities for private dental practice.

(3) The Central Middlesex Hospital, Acton Lane, Park Royal, London NW 10

The Central Middlesex demonstrated the situation common to most British acute general hospitals, patient care of high quality (and research and teaching) being provided in an aging and outmoded hospital. It now contains over 700 beds and the main buildings were constructed on the site of an old Poor Law workhouse. It was opened in 1903 as the Willesden Workhouse Infirmary. It became the Park Royal Hospital in 1921 and in 1929, when the Boards of Guardians of Poor Law Institutions were abolished, it was taken over by the Middlesex County Council. In 1948, it was taken over by the National Health Service and became part of the Central Middlesex Group of the Northwest Metropolitan Regional Board.

The Subcommittee first met with representatives of the Regional Board, the Hospital Management Committee, and senior administrators and clinicians working at the Central Middlesex. They explained the scope of clinical services provided in this district general hospital as well as the active programs of undergraduate and postgraduate teaching and medical research. They described some of the difficulties associated with working in old and overcrowded buildings which had been subject only to minor additions and renovations over the years. Yet somehow provision was always made for introducing modern advances in medical care. Typical of such modification was the partitioning of one of the medical wards to accommodate a new Coronary Care Unit (which the Subcommittee later visited) in 1967. Some time was spent discussing the Geriatric Unit. This is particularly relevant as almost 12% of the population served by the hospital are over 65 years of age. The Unit provides acute assessment for the elderly in 49 beds at the Central Middlesex where there is also a day hospital which can accommodate up to 24 out-patients from 9:00 am to 5:00 pm five days per week. The Geriatric Unit is linked with 232 beds in nearby geriatric facilities to which elderly patients may be transferred for further rehabilitation or for longstay supportive care. Patients may be admitted to the Acute Assessment Unit directly by the general practitioners. Of those admitted the average stay is approximately 26 days. About 30% die, 50% are discharged home, and 20% are transferred to Local Authority Welfare Homes or to longstay

(4) Dr. John F. H. Brotherston, Chief Medical Officer, Scottish Home and Health Department

The Subcommittee met with Dr. Brotherston in complete privacy in the middle of a spacious lawn in Regent's Park. He revealed his deep personal commitment to the egalitarian principle underlying the National Health Service and spoke as frankly and soberly of its shortcomings as he did of its basic success.

He described the evolutionary nature of the NHS and the central importance of the general practitioner service in reducing costs and enhancing quality of care (see Appendix VI). He confirmed his basic belief in the continuing and growing need for the general practitioner to supply comprehesive primary care. He felt there has been a lot of loose talk of supplanting the general practitioner by less highly trained medical assistants. He believed that a more fruitful avenue of development would involve introducing such medical assistants as aids to, rather than substitutes for, general practitioners. In this way the productivity of the GP could be enhanced and his work made more interesting by providing him competent assistants who would be able to relieve him of many of the tasks which do not require such a high degree of skill or training.

Dr. Brotherston described the changing pattern of primary care provision and the steps which are being taken to end the professional isolation of the solo practitioner and to bridge the gulf, which the Health Service had widened, between generalists and specialists. He pointed to the advantages of group practice and Government's program to encourage construction of Health Centers to provide groups of GP's with modern premises to which ancillary staff are attached. However, in Scotland he felt they had gathered impressive evidence which suggested that group practice and health centre facilities alone were not enough properly to provide the professional stimulus to ensure primary care of high quality. An essential additional ingredi ent is the interaction with specialists in the hospital setting where general practitioners should have access to diagnostic services, the Support of nursing and secretarial staff, and most important of all, the opportunity of forging intimate professional working relationships with specialist colleagues in dealing with the day-to-day problems arising in managing their patients' problems.

Dr. Brotherston described the enormous improvement the NHS had effected in the number and distribution of specialists and in the qual ity of hospital care. He reviewed the arrangements for financing hos pital services (see Appendix III) and the work of the Research and Intelligence Unit in the Scottish Home and Health Department (see Appendix IV).

(5) Meeting with Representatives of the Department of Health and Social Security

The meeting was held at the Nuffield Provincial Hospitals Trust. The Department of Health and Social Security delegation was led by Sir George Godber, the Chief Medical Officer. He was accompanied by two senior administrative colleagues, Mr. C. L. Bourton and Mr. G. P. Dodds.

With even greater emphasis than his Scottish counterpart, Sir George Godber laid great stress on the value of the general practi tioner services. The equitable distribution of good primary care pro