(Scene again shows office of Doctor No. 1.)

Doctor No. 1: "Ah, come in. Sit down. Now, Peggy, come along. Sit down here, will you. That's right. Now, Mrs. Ryman, how is the pain? How it is, Peggy." (He is addressing a mother and child named Peggy.)

Peggy: "I've still got it."

Doctor No. 1: "I'm sorry to hear that. All the time?"

Peggy: "Yes."

Doctor No. 1: "Tell me, Mrs. Ryman, have you taken the temperature?"
Mother: "Yes.

still up and down."

I have, doctor.

[She hands him a piece of paper.] She's

Doctor No. 1: "Let me look. Oh, it is. Yes. Well, now. Let's see. We've taken an X-ray and we've sent a sample off and I had those tests. They showed nothing. I think the right thing is to send her to see a specialist. What do you think?"

Mother: "Yes, I do."

Doctor No. 1: "You won't mind going to see a specialist, will you Peggy?" Peggy: "No."

Doctor No. 1: "He will talk to you just like I do and he'll examine you just like I've done. He'll be very kind to you. All right?"

Peggy: "Yes."

Doctor No. 1: "Well, now. He's there on Thursday afternoons. I don't know if I can get this Thursday, but I hope next. I'll write him a line and I'll fix up an appointment. Will you be able to get there all right to the hospital?" Mother: "Yes, I think so, doctor. We can catch a bus."

Doctor No. 1: "Yes. You have an appointment, but they don't always keep to it, I'm afraid, so you must be prepared to wait out a bit. I hope you won't have to wait too long. We'll get to the bottom of this pain. Peggy, and then we'll be able to put it right. See?"

(Scene changes to hospital outpatient department.) Receptionist (answering phone): "Hello, outpatient appointment. The endoctrine clinic? When did you want it? The 24th? Is 9:30 all right for you?" Narrator: "At one time people waited all day in outpatients department. Largely as a result of public outcry the appointment system was started in most hospitals. Some doctors say the effect has been to change the waiting time from 6 hours to 6 weeks."

Doctor No. 7. "I try to keep my patients away from the hospital outpatient department as much as possible by doing as much as I can for them myself. So often you find when they get up to a hospital outpatients they get pushed around, treated like cattle."

(Scene changes back to outpatient department in hospital.)

Nurse: "Mrs. Brickman. Mrs. Brickman. [Woman answers to name and comes forward.] Just stand on the scale, will you, please? That's right. Will you wait now up on the red chairs? You'll be called from there. [Woman walks to where nurse has indicated.]

Narrator: "And who are the specialists? The top ones are called consultants. Almost all the consultants in Britain work for the health service, and their skill is spread across the country. Most of them are on a part-time basis, paid by the session, often doing private practice as well as health service sessions in several hospitals. Working in hospitals with the consultants are their assistants. doctors already specializing and hoping to become consultants themselves. Junior house officers, registrars, senior registrars, all temporary posts held for a limited time. There is a bottleneck in promotion and many senior registrars coming to the end of their time have left the health service or even left the country; fully trained, highly qualified men who couldn't get jobs. Many GP's always specify by name the consultant they want their patients to see. Others say there's no point."

Doctor No. 5: "Normally, when I send a patient to hospital, I don't specify which consultant they're to see. I leave that to the hospital because I think they can cut down waiting time that way."

Narrator: "Whether the GP asks for a specific consultant or not, the final decision as to who will see each patient is made by the consultant himself and all he usually has to go on are the letters sent to him by the family doctors."

Consultant: "Well, I must say the doctor hasn't given us much to go on here. [He is reading description of symptoms from letter.] It's a gastric discomfort, 5 weeks, tree and C and treat."

Assistant: "Do you think you'd like to have one of the assistants see him,

Consultant: "I think so. I think he's a routine case. [He goes on to next letter.] Well, I must say this doctor really does write excellent letters, nicely typewritten, giving us all the relevant facts. I always like seeing his cases. If you don't mind, I'll take him myself. [Next letter.] Well, there's quite a problem here and it's up your garden path. Case of jaundice. Would you like to take him?"

Assistant: "Well, we'll see where the path leads.”

Consultant: "Thank you. I think that's a fairly routine case. You can get one of the assistants. Now I think this is urgent. The doctor's asked for an urgent appointment. We'd better fit him into the next list. There's a question of cancer."

Assistant: "We can certainly manage that, sir.”

(Scene shifts to waiting room.)

Nurse: "Mr. Edward Barker. Mr. Edward Barker." [Man rises from chair and answers call.]

Narrator: "And the health service specialists deal with 35 million appointment every year."

(Scene shows patient at receptionist's window in hospital.)

Patient: "I'd better make another appointment for this diabetic clinic, miss. This Wednesday."

Receptionist: "Have you attended the diabetic clinic before?"

Patient: "Yes. Once."

Receptionist: "Thank you. Can I have your white card?"

Patient: "Yes." [He hands receptionist card she has requested.]

Receptionist: "This Wednesday at 1:40. Is that all right for you?"

Patient: "One-forty? Yes. All right. That'll suit."

Doctor No. 22: "A consultant primarily exists to give the second opinion in cases where the GP wants further help. What's happening today is that the consultant, or the hospital, if you like, tends to hold onto the patient after seeing him for the first time. He doesn't send him back to his GP sometimes for weeks, sometimes for months. As a result of that, of course, the patient thinks that the GP is no longer capable or even no longer interested in dealing with him and your doctor-patient relationship goes hang, the hospital gets cluttered up with long lists of cases which no-for no reason should continue to attend there after the primary consultation.

Narrator: "The gulf between GP's and consultants has widened. sultants compare this with the days before the health service.”

Older con

Consultant: "Well, in the old days, when I first started, the consultant depended entirely for his bread and butter on the private work sent to him by the family doctor. Consequently he took a good deal of trouble to get to know the family doctor and to understand his problems. The modern consultant today, with his income guaranteed entirely by the State, and very little private practice about, tends perhaps to adopt rather a more off-hand attitude toward the general practitioner which I think is to be deplored. That's why the domiciliary consultation scheme is such a good thing, because it does bring the general practitioner into relationship with the consultant in the same way that private practice did in the old days."

Narrator: "The domiciliary consultation scheme. When a patient is too ill or too old to be moved, the GP can call in a consultant to see the patient in his home. There are over 300,000 of these visits a year. This scene is typical. A cottage in Somerset. An old lady too ill to move. The family doctor, the heart specialist with his electrocardiogram. (Scene shows specialist taking cardiogram.) Afterwards, consultant and GP talk it over out of earshot." (Scene shows GP and consultant outside of described cottage.)

Consultant: "I agree that this is a case of hypertensive heart disease and I should continue treating her just as you are, but I would add a mercurial diuretic 2 days each week. The real problem here seems to be the nursing. Can she be looked after properly at home?”

Doctor: "Yes, I think we can carry on as we have been. The husband is very good and the daughter lives not very far away. I think we can nurse her at home, all right."

Consultant: "Good. Well, shall we go in then?"

Another consultant: "I feel that anything we consultants can do to improve the general practitioner-consultant relationship is well worth doing. I personally would like to see general practitioners working in hospitals far more than they do today."

Narrator: "But most GP's are excluded from the hospitals. The specialists live in one world, the GP's in another. And at the end of the day's outpatients, 76123-61-pt. 2- -35

the letter is the only link, as the consultant writes the family doctors about the patients they've sent him.'

(Scene shows consultant in his office dictating to secretary.)

Consultant: "Dear Dr. Cranshaw. Thank you for your letter about this lady. I've little to add to your opinion. She complains of 2 months' vague pains in the left chest and appears to be very anxious about her heart since a friend at the office died. There are no physical signs of any organic disease and her symptoms do not resemble anything serious. I explained to her that I had nothing to add to your opinion, but perhaps she will believe me because I am sitting in a white coat at a hospital desk. I didn't order an X-ray, but if she still worries, that might convince her even more. I have discharged her back to your care, but should be glad to see her again if she has any more trouble. Yours sincerely. The next one is Dear Dr. Playbrook. Thank you for your letter about this young woman. (He stops dictating and speaks to his secretary.) It's not really a letter. They've sent a card and on the back's question mark-can you read this writing?-think it's anemia. Wish he'd write a bit more. (Resumes dictation.) I've got a clear story of 6 months' loss of weight and appetite, heavy gastric pain and occasional vomiting. On examination she's a large hard mass in the epigastrium which I felt sure was a carcinoma of the stomach. I'm afraid the barium meal has now confirmed this opinion. I'm admitting her to hospital as soon as possible with a view to operation, but I am afraid the outlook is rather grave. (Again interrupts dictation to speak to secretary.) You know, I think if he's going to ask me to look at the case for my opinion, he ought to have a good try at making a diagnosis himself. Besides, if he'd spotted it a good deal earlier, the outlook might have been a bit better. Well, now, next I've got (and he resumes dictation)-Dear Dr. Halgrave. This young woman gives a history of three attacks of loss of consciousness and mental confusion in the last month. These symptoms came on 1 week after she fell from a ladder. Angiography shows a large subdural hematoma on the right side and she has been admitted for operation tonight. I'll send you another report about her in the morning. (He again speaks to secretary.) Now, that's the sort of case I really do like to have. You know, the diagnosis is a bit obscure and the consultant, when he does make it, feels that he's being of some use. Well, now, there's one more case here. (Resumes dictation.) Dear Dr. Palmerston. I have found that this lady is entirely insane * (Scene fades out.) (Scene fades in to office of Doctor No. 1.)

Doctor No. 1: "Well, I know what's brought you here, Mr. Sapsfort. It's your veins, isn't it?"

Patient: "Yes, sir."

Doctor No. 1: "Hurting you a lot?""

Patient: "Yes, they are very painful. When could you get me in a hospital, sir?"

Doctor No. 1: "Well, that's the point. You're not an urgent case. And the trouble is that the beds are used for the urgent cases first, before they can get nonurgent cases like you in. I'll tell you what I'll do. I'll ring up the hospital and find out what your position is on the waiting list. That all right?" Patient: "Yes, sir. Just tell them I'm fed up with waiting." Doctor No. 1: "Yes, well, I may do." Narrator: "In 1948 the state took over 3,300 hospitals in Britain. Half a million beds in a great variety of hospitals. The big teaching hospitals, the public and municipal hospitals, even the old poor law and voluntary hospitals. When the health service took over, there were long waiting lists for the less urgent cases. Today, with free treatment, these waiting lists are longer, although the tide has been turned. All doctors are agreed that one of the greatest things the health service has done is to raise the standard of all the lesser hospitals in the country. This hospital in Bedford is an example. Now it no longer matters where you enter hospital, you'll receive treatment comparable with the best. On the one hand, there are the consultants, men of equal grade throughout the country, bringing high standards of skill and experience to every hospital. Then there's the equipment with which they work. In this hospital two new operating theaters have been installed. With this equipment, and with the consultants now appointed, operations that were never done before in Bedford take place here as a matter of routine. In the process of improvement. hospitals like this have made the most of what they've got. The old operating theater has become a new dispensary. The old dispensary has become a much needed extension of the casualty department. In hospitals everywhere it's been a case of improvisation, of reequipping and brightening up. But no amount of

reequipping or brightening up can overcome the national shortage of beds, a shortage which is worse in some parts of the country than in others."

Doctor No. 2: "In my area the hospital shortage of beds is mainly concerned with maternity, and, indeed, I have patients who have their babies at home who, in my opinion, should certainly be in hospital. I just can't get them in. Last week only we had a mother who lost her baby who should, in my opinion, have been in hospital."

Narrator: "Over half the hospital beds are taken up by mentally ill, the old and the chronic sick. The old people are a growing problem. These times of medical advance and longer life have produced an aging population. It's true that a great deal has been done in some places-here in Oxford, for example to shorten their stay in hospital, by early treatment, by intensive nursing, by physiotherapy, by undersanding and encouragement. But even when these people can walk again, where can they go? The problem is often more a social one than a medical one. A thousand homes for old people have been started-more are needed. As it is, thousands of hospital beds must be set aside for old people who have no where else to go. But the real problem is new hospitals. We still ask far too much of hospitals like this one in the north of England, built nearly a hundred years ago. No amount of improvisation or reequipping can expand these Victorian walls. The voluntary boards and committees meet-laymen and doctors. This general practitioner is chairman of one of the committees."

Doctor No. 23: "The trouble with this hospital is that the waiting list has got out of hand, Just listen to this. General surgery, 877 cases, some of them waiting for 3 years. Orthopedics, 701 cases, some of them waiting for 6 years. Genitourinary surgery, 734 cases, some of them waiting 61⁄2 years. And so on, pages and pages, sick people waiting for beds in hospital, beds that we haven't got. In my opinion, the weakest point in the national health service is the capital program. We need fresh bricks and mortar for sick people and we're not getting them. Meanwhile, we shall have to make do with these temporary buildings on this congested site, temporary buildings that have lasted far too long."

Narrator: "In between the original buildings, every square yard has been put ot use. This corrugated iron shed was built in 1918 for war casualties. Today it's still in use as the ear, nose, and throat ward of this hospital. Inside every bed is occupied and a thousand cases a year are effectively treated here, despite the difficulties, by an efficient staff. Asbestos sheeting, corrugated iron, hardboard, timber-there's no longer any room for more. It's hard to realize that this is a key hosptial serving a large area in 1958. How does this problem strike the doctors whose work depends on hospitals? A leading physician."

Doctor No. 24: "We must go back to 1870 to find 10 years in which so little has been spent on hospital buildings. And yet you know we have nearly half a million people on the waiting lists. Meanwhile, we have extremely well trained and underemployed medical staff waiting to deal with this problem. The problem could be dealt with if only there were new hospitals and new outpatient departments. Waiting lists and waiting times must be abolished. This is not an expensive service. No evidence has been found of waste anywhere within the service."

Narrator: "A leading surgeon."

Doctor No. 25: "It's all very well to say that we want new hosptials and so on. Of course we do. But who's going to pay for them. The cost of this national health service is fantastic-over 700 million pounds a year. And if we're going to spend more money, it must presumably either come from extra taxes from bigger insurance schemes or by patients themselves contributing to the cost of their own treatment. The choice then before us is surely, either we've got to muddle on as we are or else we have to put our hands in our pockets."

Medical Health Officer: "Don't forget. The national health service is only 10 years old. And it'll take at least another 15 years until we really get things to go the way we want them to go."

Doctor No. 9: “I think we're having a very good service. But where we need to spend a great deal more money is in attention to patients in their own homes, in doctors' surgeries, in fact, outside hospital."

Doctor No. 3: "Letters in the papers are always saying that our health service is the envy of the world, but there's not another ruddy country that's copied it."

Doctor: "How can anyone criticize the health service? I think it's the greatest thing that ever happened."

Doctor: "It's been a great help to us doctors to know that our patients aren't always wondering about where the money's coming from to pay the doctor's bill."

Doctor No. 20: "When the national health service started I felt that there was something being taken away from us and my immediate reaction was to do less for my patients. But, in fact, now I'm doing more and general practice to me is infinitely worthwhile and gives great pleasure."

Narrator: "And there will be more patients in the waiting room tomorrow." (Scene shows empty waiting room of Doctor No. 1.)

The commentary was spoken by Colin Wills.

Photographed by Eric Deeming.

Recorded by Bob Saunders and Frank Dale.
Sound editor, Eric Brown.

Film editor, Harry Hastings.

Written and produced by Richard Cawston.

(Scene shows Doctor No. 1 asleep in bed and phone beside his bed starts ringing. He awakens, turns on light, and answers phone.)

Doctor No. 1: "2010. Yes, speaking. Who is it? Oh, I know. Yes, you joined my list this morning. Yes, what is it? I understand. Yes. I'll come along. Right. Goodby." (He hangs up phone.)

Superimposed on film: "On Call to a Nation," a BBC documentary.

The CHAIRMAN. Without objection, the committee will recess until 2 p.m.

(Whereupon, at 12:30 p.m., the committee recessed, to reconvene at 2 p.m. the same day.)

AFTER RECESS

(The committee reconvened at 2 p.m., Hon. Cecil R. King presiding.)

Mr. KING. The committee will please be in order.

Is Dr. Butler in the room? Come forward, Doctor. Will you identify yourself for the record, Doctor?

STATEMENT OF DR. ALLAN M. BUTLER, PAST CHAIRMAN AND MEMBER OF THE EXECUTIVE COMMITTEE, THE PHYSICIANS FORUM

Dr. BUTLER. Representative King and members of the committee, I am Dr. Allan M. Butler, and I am appearing here in behalf of the Physicians Forum, a national organization of physicians established 22 years ago as a forum for the consideration of proposals to improve the availability, efficiency, and quality of medical care. Our members, who number over 1,000, are mainly private practitioners belonging to their county medical societies or other recognized professional associations.

My experience as a teacher, scholar, and practitioner of medicine for 35 years includes having been professor of pediatrics at Harvard Medical School, chief of the children's medical service, Massachusetts General Hospital, associate editor of the New England Journal of Medicine and of the Journal of Clinical Investigation, past president of the American Pediatric Society and of the New England