The planning of health services: studies in eight European countries

Ac . v LUrtl)/ ~uQo e. e planning of health services Studies in eight European countries REGIONAL OFFICE FOR EUROPE World Health Organization _COPENHAGEN , ' THE PLANNING OF HEAL TH SERVICES [ Arch. Copy \ THE PLANNING OF HEALTH SERVICES Studies in eight European countries Edited and introduced by G. McLACHLAN Secretary Nuffield Provincial Hospitals Trust London , England WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE COPENHAGEN 1980 ISBN 92 9020 195 9 © World Health Organization 1980 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Con- vention . For rights of reproduction or translation , in part or in to to, of publica- tions issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen(/), Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country , territory , city or area or or its authorities, or concerning the delimitation of its frontiers or boundaries . The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned . Errors and omissions excepted, the names of proprietary products are dis- tinguished by initial capital letters. The views expressed in this publication are those of the authors and do not necessarily represent the decisions or th e stated policy of the World Health Organization. PRINTED IN DENMARK Reissued under ISBN: 9789289024952 (print) in 2025. Originally published under ISBN-10: 9290201959. CONTENTS Page Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii INTRODUCTION .... ... . . ............................ . Regionalization in the countries studied. . . . . . . . . . . . 4 Some planning issues . . . . . . . . . . . . . . . . . . . . . . . . I 0 Health services financing. . . . . . . . . . . . . . . . . . . . . . 12 The health information system and health services research as a basis for development. . . . . . . . . . . . . 14 CHAPTER I. SCOTLAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 The fundamentals of planning in Scotland . . . . . . . . . . 20 National Health Service in Scotland . . . . . . . . . . . . . . 23 The Greater Glasgow Health Board . . . . . . . . . . . . . . . 33 The Border Area Health Board. . . . . . . . . . . . . . . . . . 41 Industrial health services. . . . . . . . . . . . . . . . . . . . . . 42 Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 CHAPTER II. IRELAND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Health planning at the national level . . . . . . . . . . . . . . 52 Financing of health care . . . . . . . . . . . . . . . . . . . . . . 57 Planning of community health care. . . . . . . . . . . . . . . 62 Social services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Planning for hospital care . . . . . . . . . . . . . . . . . . . . . 68 The South-Eastern Health Board . . . . . . . . . . . . . . . . 73 Planning regional community care . . . . . . . . . . . . . . . 76 Planning regional hospital care . . . . . . . . . . . . . . . . . . 79 Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Annex 1. Voluntary health insurance schemes. . . . . . . 85 Annex 2. The General Medical Services (Payments) Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 CHAPTE R III. AUSTRIA: THE TYROL . . . . . . . . . . . . . . . . . . . . . . 89 Regional planning in the Tyrol. . . . . . . . . . . . . . . . . . 90 Relationship between the overall socioeconomic situation and health planning. . . . . . . . . . . . . . . . . 94 The health insurance system . . . . . . . . . . . . . . . . . . . 95 Physicians and their professional association in the Tyrol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 iii The public health services . . . . . . . . . . . . . . . . . . . . . 99 Hospital planning - MEDIPLAN . . . . . . . . . . . . . . . . 102 Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l 03 CHAPTER IV. FEDERAL REPUBLIC OF GERMANY : SCHLESWIG-HOLSTEIN . . . . . . . . . . . . . . . . . . . . . 107 Regional planning in Schleswig-Holstein. . . . . . . . . . . . 108 Public health services in Schleswig-Holstein . . . . . . . . . 110 Hospital planning . . . . . . . . . . . . . . . . . . . . . . . . . . 111 The organization and operation of the sickness fund insurance system . . . . . . . . . . . . . . . . . . . . . . . . . 114 The association of insurance fund physicians in the Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 The pension and retirement fund . . . . . . . . . . . . . . . . 117 An approach to a Land information system . . . . . . . . . 118 Coordination of plans. . . . . . . . . . . . . . . . . . . . . . . . 119 Emergency services in the Land . . . . . . . . . . . . . . . . . 120 Preventive services . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Social infrastructure planning . . . . . . . . . . . . . . . . . . 124 Health manpower and comparisons with the Federal Republic . . . . . . . . . . . . . . . . . . . . . . 125 Psychiatry and its position in the Land . . . . . . . . . . . . 126 Environmental health protection . . . . . . . . . . . . . . . . 128 Pharmacies, pharmaceutical supplies, and pharmaceutical control. . . . . . . . . . . . . . . . . . . . . 129 Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 CHAPTE R V. HUNGARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Health planning at the national level . . . . . . . . . . . . . . 133 The departments of the Ministry of Health. . . . . . . . . . 136 Planning and decentralization . . . . . . . . . . . . . . . . . . 138 Budapest's position within the national health system . . 139 Baranya County's position within the national health system . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 CHAPTER VI. THE USSR: MOSCOW AND THE LATVIAN SSR . . . . . . 147 Planning at all-Union level. . . . . . . . . . . . . . . . . . . . . 147 The Latvian Soviet Socialist Republic and its health iv administration . . . . . . . . . . . . . . . . . . . . . . . . . . 149 The planning process . . . . . . . . . . . . . . . . . . . . . . . . 152 An experiment in management at rayon level . . . . . . . . 154 Health care for children and women in the Latvian SSR . . . . . . . . . . . . . . . . . . . . . . . . . 155 Emergency services in Riga . . . . . . . . . . . . . . . . . . . . 160 The training and use of health personnel other than physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Summary of data concerning the principal republic clinical hospital , Riga. . . . . . . . . . . . . . . . . . . . . . 162 Trade unions social insurance and major enterprises. . . . 163 Summary of progress in the Republic . . . . . . . . . . . . . l 64 Comments .............. .. ................ 165 CHAPTER VII. SWEDEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 National economic planning . . . . . . . . . . . . . . . . . . . 173 The health planning role of the National Board of Health and Welfare . . . . . . . . . . . . . . . . . . . . . . . 174 Occupational health. . . . . . . . . . . . . . . . . . . . . . . . . 178 The National Institute for the Planning and Rationalization of Health and Social Welfare Services . . . . . . . . . . . . . . . . . . . . . . . . . 179 Financing of health and medical care. . . . . . . . . . . . . . 180 The Malmohus County Commune: its planning and resources. . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Financial and budgetary planning. . . . . . . . . . . . . . . . 185 Long-term planning of acute hospital care . . . . . . . . . . 189 Long-term planning of dental care . . . . . . . . . . . . . . . I 90 Long-term planning of health information systems. . . . . 192 The Dalby primary care district . . . . . . . . . . . . . . . . . I 93 Long-term planning of primary health care. . . . . . . . . . 19 5 Long-term planning of long-term and institutional care. . 197 Long-term planning of psychiatric care . . . . . . . . . . . . I 98 Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 99 CHAPTER VIII. DENMARK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 National economic and land-use planning. . . . . . . . . . . 204 L 'ccentralization of health and social service administration . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Financing of health and social services. . . . . . . . . . . . . 208 National resources for health and social service planning ....... . ......... . ..... .. ..... 21 0 National planning of the hospital secto r. . . . . . . . . . . . 2 I 5 National planning of the primary care and social service and other health sectors ............... 218 Information system for national health planning. . . . . . 222 Aarhus County: administration and health services . . . . 224 County planning of the hospital sector . . . . . . . . . . . . 232 V vi County planning of primary care and social services . . . . 234 County land use and infrastructural planning . . . . . . . . 235 The municipality of Aarhus: administrative structure and health services. . . . . . . . . . . . . . . . . . . . . . . . 236 Health and social services planning at municipality level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 FOREWORD The different ways in which countries plan and organize their health ser- vices make an interesting study in themselves, and nowhere is there such a variety of approaches as in Europe. In the present economic climate, however, planners of health services are being compelled to look closely into ways and means of providing services more cheaply without loss of quality. In attempting to do this they may well find inspiration, and they will certainly find food for thought, in what other countries have done or propose to do. It was in this spirit that the WHO Regional Office for Europe commis- sioned the studies presented here. They were carried out between 1972 and 1977, but the authors have brought them up to date on the basis of later developments and the comments of the countries. The WHO Regional Office for Europe expresses its gratitude to the many persons in the various countries who gave unstinted help to the authors of the studies, and it thanks the authors for the studies they prepared. vii INTRODUCTION G. McLachlan 1 The purpose of these studies was to obtain an overall view of the regional planning of health services in Europe. The eight countries visited are different culturally and socially, and each is unique in its history, geography, and top- ography. Consequently no uniform approach was adopted in the studies; rather, it was left to the authorities of each country to stress what was regarded as the most relevant, most interesting, and most important issues in that coun- try, what developments were taking place in planning, and what were currently the major influences in the operation of the health services. The approach , therefore, was informal. It differs from that taken in Health services in Europe,a which is concerned with the structure of the health services, and it looks at the planning of those services from a viewpoint different from that of the increasing literature on the important subject of planning.b Even in those countries in Europe and North America where there is no unified health service system the need for a regional basis for planning the health services is beginning to be recognized, and the fundamental issues in- volved are coming under discussion. An example is the USA, in which regional- ization is the subject of a recent publication.c The current emphasis on regional planning in the USA is related to the question of a national health insurance. The assumption of Public Law 93-641 and the consequent regulations, which set up some 200 health systems agencies on an area basis throughout the USA, is that some kind of national system will be developed. Such a development presupposes some grouping of areas with their own particular geographical and 1 Secretary, the Nuffield Provincial Hospit als Trust , London, England . a WHO Regional Office for Europe. Health services in Europe , 3rd ed. Copenhagen, 1980 (in press) . b See, inter alia, WHO Technical Report Series, No. 409,439 , 456,472; WHO Public Health Papers, No . 43, 46, 66, 67; WHO Public Health in Europe Series , No . I . c Ginsberg, E., ed. Regionalization and health policy. Washington , United States De- partment of Health, Education and Welfare , 1977 (Publication HRA 77-623). economic characteristics. Regional grouping is required not only because of the great physical size of the USA and the need accordingly to break it down into reasonably sized areas with specific identities, but also because such areas must constitute units capable of being effectively administered and of being identi- fied at the national level for accountability purposes. In Europe this process has been taking place over a much longer period and so gradually that we have possibly taken it for granted, forgetting that the search for effective administration has been in progress for centuries and is not unique to the health sector. Planning itself is a multidimensional process in that political considerations with all their many facets have to be taken into account, and it is an integral part of politics. It has to be flexible in practice to allow for change over time, and it has to be sensitive to cultural, social, economic, and demographic as well as to political conditions. This study of planning in various European countries is intended to describe the experience of countries with different political and economic systems. The accounts of each country when taken together accord significantly with other studies using different approaches and demonstrate not only the wide variety of systems in operation but also the marked similarity of most of the residual problems, which may well be basic problems, attributable as much to human failings as to the effects of forms and structures. The fact that, universally, central governments are having to play a greater part in the financing of health services, either by providing funds directly or by supervising the operation of such subsystems as have developed because of insurance reimbursements, means that they are increasingly being forced to develop and implement plans that everywhere have the common feature that they entail above all the hand- ling of incomplete information. The countries of Europe, while enjoying, or perhaps because they enjoy, a high standard of living, still suffer from a great amount of illness. Communi- cable diseases , which had such devastating effects in the nineteen th century, are kept fairly well under control, but control is difficult and expensive and there is always the threat of resurgence, the effects of which can occasionally be disastrous. Thus, from time to time, newly discovered strains of influenza still cause havoc in the industrialized communities of Europe. Epidemiologists have highlighted the present high incidence of acute cardiovascular disease, road accidents, and the diseases that arise from stress or old age, these last giving special emphasis to the need for special care for the aged and the mentally ill and mentally handicapped. There is an ever increasing call from the health sector on national resources and, even when the economy is flourishing, anxieties about costs are no less in evidence. Indeed, there is at present a feeling that the post-war boom in the development of health services in many countries may be over, and further development will have to be more closely scrutinized than ever before. Govern- ments are increasingly being forced to establish priorities for the use of re- sources, not just for health generally but also - and this raises special prob- lems - within the health sector. This is a consequence of their being brought directly into the health field, even in mixed economies, to help pay for the implementation of public policies adopted as a result of the widespread accept- ance of the dictum that "health is a right". It is therefore hardly surprising that 2 most governments want some say in decisions on any policy that is likely to involve public finance. Because of this there has been a movement towards more planning of services. A great deal of emphasis has thus been placed on re- gional planning, since there are few nations small enough to plan and operate effectively directly from the centre. In this study, therefore, "regional" planning assumes decentralization to subnational authorities for planning purposes. Regionalization and planning - definitions Given the nature of health problems and the logistical problem of getting services to those in need WHO, and particularly the European Region, has long been involved in the question of the planning of health services. Not that the questions involved in systematized planning are unique to health; in 1967,0 it was pointed out that planning pressures were known long before the organiza- tion of health services became a critical issue in national policies. Universal standard practice in health matters is scarcely practicable, since it is inevitably an integral part of general socioeconomic planning; accordingly it is bound to vary from country to country and even in the same country at different times. Thus regionalism has been defined as a doctrine or practice of subdividing or decentralizing a country into regions on a political, economic, or other basis. Again, the Shorter Oxford Dictionary defines a region as "a place , state or con- dition, having a certain character or subject to certain influences". The making of regions is therefore the defining of particular areas within a country for some purpose, often concerned, as in health , with government or the regulation of services on a local basis. The concept of a region for health services varies widely in European countries, in terms both of the size of the population covered and of the principles on which medical services are organized . The concept of regionalization implies the need for a structure embracing sometimes disparate organizations that may be subject to some process of rationalization but in any event possess common characteristics and provide parts of what can be conceived as a comprehensive whole. The essential basis of the concept is the prospect of a form of order and the promise of procedures that in theory at least facilitate the better management and optimum use of resources. The affinity of the concept is thus with the concept of order in society, implying governance in some form from a centre. The concept is rooted strongly in European political history. Thus, the Romans ruled vast tracts of the pre-Christian world by a form of regionalization with a bureaucracy that governed through delegation. Indeed, a form of regional devolution, the outline of which was simple even if the detail was complex, has been a ruling feature in many societies. Yet, since the general concept is not limited by size, a region can be small enough to embrace defined topographical and other characteristics. In modern societies regionalization is a convenient administrative device to enable governments, which have come to be the major sources of finance, to a WHO Technical Report Series, No . 350, I 967. 3 carry out public policies effectively. Thus it has been utilized to avoid irregular growth in specific geographical areas, to achieve better distribution of resources, and to equalize opportunities for development. Regionalization is indeed a natural stage in the development of public administrative structures, a way of rationalizing and making efficient the machinery of government. Administrative convenience and efficiency are not the only driving forces, for there is also now a philosophy of regionalization based on the stimulation of local pride, on quickening recognition of the dangers of local apathy and some- times of demoraliza tion inherent in undue centralization. This approach is of particular importance when there is a need to mobilize local initiative and re- sources as a necessary complement to central action for effective health services. REGIONALIZATION IN THE COUNTRIES STUDIED Some common features The most common feature of regionalization in practice is the requirement to define clearly the functional and geographical areas of responsibility in the provision of services without making the catchment areas too exclusive. The different forms of health service units that have been developed to ensure the optimum use of the technology utilized in highly specialized care tend to have the effect of concentrating the units in centres of large population. These be- come the natural bases for the development of a regionalized organization. In Europe there is neither standard size nor standard form of region, but the basic geographical area for primary health care purposes seems usually to be one having a population of between IO 000 and 50 000. Several such areas may to- gether make up a catchment area for the local hospital , which may provide only the most common specialties although, depending on the geographical circumstances, it may have the fairly comprehensive range of specialties usually associated with the district hospital. The regional hospital tends to provide specialist services for a population of up to 1000000 people. In the larger countries the system may be supported by a series of national institutes catering for the super-specialties and rarer forms of medical care as well as having re- search and educational responsibilities. The clearest picture of the elements making up a regionalized organiza- tional structure for planning purposes can be discerned in the eastern European countries, where the geographical boundaries tend to be clearly specified for all units and the distribution of responsibilities and authority an1ong the units at different levels is usually specified in considerable detail. In western Europe the organizational structure seems slowly but surely to be taking much the same form. This is most evident with regard to the organization of hospital services, which employ most resources and accordingly attract most attention when reforms involving rationalization are in the air. In Sweden the concept of a rcgionalized structure was developed in the early 1960s , and the reorganiza- tion planned in Denmark points in a similar direction. The nationalization of 4 the Scottish hospitals in 1948 was a very important step towards the more uni- fied health service structure introduced in 1974 to amalgamate the hospital, local authority, and primary care sectors. It is notable there that regionalization has involved a different view of size ; the former hospital "regions", of which there were 5, have been replaced at the subnational level with 14 "areas". Although in many western European countries the primary care level has been neglected from an organizational point of view, the recent renewed interest in this sector has led to moves for its incorporation into the regional structure to ensure more efficient organization and better integration with the other parts of the health service. In some countries this has led to a policy of health centre development (sometimes both health and social centres) to cover de- fined geographical areas (in particular in Scotland and the eastern European countries); in others such initiatives have been restricted to the establishment of specialized group practice in a variety of forms and settings. Lines of authority Partly owing to general political developments , partly owing to the struc- tural reorganization of the health services, and partly owing to changes in the education and training (and consequently the status) of professional health per- sonnel, the structure of authority and decision making in the health services of many countries is constantly in process of change . The long-standing question of centralization versus decentralization and the complex, more modern issue of single authority versus consensus in health services management are at the heart of the problem. The entry of disciplines other than medicine into the upper echelons of health administration has raised questions about the leader- ship role in management of the public health officer, hitherto taken for granted. The wide interpretations of what the function of the community physician should be also make for a certain confusion in comparisons between countries unless the actual planning functions are closely defined. The question of centralization or decentralization of decision making has become an important political issue in many European countries during the last decade. In Austria and the Federal Republic of Germany the Land system ensures that most decisions are taken and carried out at Land level, the federal role being seen principally as one of support, advice, and coordination. In Sweden extensive authority over hospital development has been vested in the counties, although the central authorities have kept control over the dis- tribution of medical manpower. In Denmark recent developments have included extensive decentralization of the power of decision making to the counties. In the eastern European systems considerable decision-making authority has been retained at the central level, although there seems to be some sign of a ten- dency, where the size of the local administration justifies it , towards delegating more of the decision making to lower levels. National authorities thus seem to see the role of the central authority as being more concerned with the development of guidelines for health service development. In this role they are involved in setting standards and norms and coordinating the development of health services resources with the general socioeconomic development of the country, as well as in ensuring the better 5 distribution of such resources over the country. Regional and local authorities thus have responsibility for applying such guidelines, standards, norms, and re- source allocations to the solution of the local problems of defined populations. The method and degree of control and authority exercised bureaucratic- ally throughout the health services vary among the different countries. In the eastern European systems a clear hierarchical control is established. In western Europe, while the public hospital sector has always been under fairly strict control, recent trends involving the channelling of public funds to private hospitals have brought in their train a larger measure of public regulation of such institutions than before. Private practitioners tend to have a considerable degree of professional independence in most western European countries, but it is evident that the effect of planning requirements is beginning to be found restrictive in operational terms. Considerable differences are also found in how such controls are exercised. In the eastern European systems the medical profession is more involved in health services management than in those in western Europe. As a general rule the top positions, both in health institutions and in health services management, are occupied by physicians. Thus directors of hospitals and of county, regional, and national health services all tend to be recruited from the medical profes- sion. Such managers usually have both a clinical and an administrative back- ground and training. In the western European systems there is often a marked distinction be- tween clinical and administrative authority. While physicians always have com- plete clinical responsibility, administrative leadership in health institutions, in county health services, in many operating divisions in ministries of health, etc., is often exercised by professionals with a training other than in medicine. Many are economists and lawyers, but there are also some graduates of special training programmes. In Scotland and Ireland nonmedical civil servants are involved in the organization and development of programmes at national and sometimes at local level. Although in the Scandinavian countries and in central Europe there is a clear hierarchical authority among clinicians in hospital departments, management decisions are usually taken in effect by consensus. In most countries advisory groups assist management personnel in carrying out their duties, and how they work depends on local circumstances and the accidents of history. In eastern European and Scandinavian countries these advisory groups have fairly substantial (medical) professional representation. In Scotland there is a majority of nonmedical personnel on the executive boards of the health authorities. While in all countries final decisions on administrative and financial policy matters are taken by politicians at the national level through the ministry of health, the government, and the parliament, there are considerable differences in political involvement at lower levels. Active super- vision by politicians of planning both at the local and the regional level is the rule in eastern European and Scandinavian countries, but it is less at local area level in Scotland and at the Land level in Austria and the Federal Republic of Germany, reflecting thereby the relative degree of public participation. In the management and operation of hospitals the physician is undoubtedly regarded as the leader of all the health professions in relation to policies af- fecting clinical services. It is of interest to note, however, that in some European 6 countries other health workers have begun to question the leadership of the clinician and to be less subservient to his opinions on policies unless they are supported by the logic of management. This is a corollary of the awareness that hospital care tends to depend more and more on the supporting services of scientists as well as of engineers and technicians. Such changes in attitude invariably compel reconsideration of the role of the physician in management. Above all, they pose the need for expertise in teamwork. Experience in Denmark, Scotland, and Sweden demonstrates ac- ceptance of the fact that the management of hospitals involves a number of complementary skills, some of which are nonmedical. Where experience is still lacking in all countries , or is at least at a premium, is in the use of disciplines with few traditions in health affairs (e.g., systems analysts , operational re- searchers, scientists, or economists). It is, however , not difficult to believe from the evidence in each country that , with the increasing demand for more scien- tifically based management methods in the health services, a wider professional expertise and the use of multidisciplinary teams in health services management could become a normal feature in the years ahead. It is difficult to isolate this problem from the changed status of the public health officer. Since the time when microorganisms were associated with disease - in some cases even before - doctors and other medical workers have been the leaders in protective and pre- ventive work in the community. The medical officer of health in Scotland (be- fore the reorganization of the health services), the district medical officer in Austria , the Amtsant in the Federal Republic of Germany, the county medical officer in Ireland, and the epidemiologist and environmental doctors in eastern Europe are all examples of physicians with such preventive, epidemiological , and environmental protection roles. At the present time, however, several fac- tors have led to changes in traditional public health practice. The major one has been the decline in the prevalence of communicable diseases . In some of the countries under study, especially the German-speaking ones, the insurance fund system, with its support for the practitioner on contract, has been a contribu- tory factor, weakening the authoritative position of the public health physician, especially in the field of immunization. A similar phenomenon can be observed in Ireland and Scotland , where reorganization has mcluded the transfer to general practice of preventive tasks in traditional public health fields such as immunization. It might have been expected that the increased preoccupation with the differentiation ol" the health services and the demonstrable need for better co- ordination through improved management would have strengthened the position of the public health officers in European health systems . This does not, however, seem to have taken place. In Sweden the regional medical officer seems to have been largely by-passed in the enlarged management tasks of the county services. In Denmark the recent reorganization does not appear to have given the public health officer the central place in county health administration that might have been expected. In Scotland, however, the change from medical officer of health, with a fairly narrow spectrum, to community medicine specialist raises the important question of whether a change of direction is taking place. Does making him responsible for assessing the need for both cura- tive and preventive health services, and in so doing requiring him to use a variety 7 of skills, meet a need for a specialist practitioner in population medicine as a member of and essentially primus inter pares in the health service management team, or does it give a single individual too many tasks? The role of the public health officer in occupational health is also vague in most western European countries . In environmental health, too, his role is sometimes uncertain, owing to the split in responsibilities bet ween local authori ties and central governmental and other services. Engineers and other professions working with environmental problems tend to be employed by authorities other than the health services. The role of the doctor in these matters is not always clear. Only in the two eastern European countries studied has a public health officer continued in a key administrative role, although even there prevention tends to be a multidisciplinary affair. The question arises whether the diminish- ing role of the public health officer in other parts of Europe has created the problem that there will no longer be a focus in the community for certain important functions. It will be important in the future to monitor this by ob- servation of current practice - whether or not , for example, the risk taken by giving primary care practitioners and paediatricians responsibility for immuniz- ation and other tasks is reasonable or too high. It is clear, too, that increasing specialization in preventive services involves the danger that the care of women and children could become so fragmented as to lead to more costly and not necessarily more effective services. Indeed, in some countries local authorities now have no single public health official from whom they can obtain advice. The danger exists that care could become too remote under a too specialized system relying on advisory subsystems, and that in the long run the community will suffer. This is a real problem and is highlighted by the study; it has to be kept under review to ensure that the best managerial, preventive, social, en- vironmental, and educational skills are mobilized for the public benefit. Priorities Although there is considerable interest in the philosophy and practice of preventive services as a means of grappling with health problems in the early stages, in practice most countries tend to devote an overwhelming part of the resources available to health to care of the patient, and in particular to insti- tutional care. Maternal and child health services seem to be in a reasonably flourishing state in most European countries, but other aspects of personal pre- ventive services are much less developed. As has been noted earlier, the respon- sibility for environmental health protection has shifted in some countries from ministries of health to ministries of the environme nt or other ministries, which has in the main not contributed much to the establishment of effective en- vironmental protection programmes. While occupational health, too, has tradi- tionally received considerable attention because of the special interest of or- ganized labour, a clear responsibility for it has not always been established. Much interest has centred around the improvement of primary care services as a means of developing more relevant and less expensive health care pro- grammes, but specific changes have been very slow in most countries. Part of the problem seems to be uncertainty about the relative roles of the physician 8 and other health professionals. In the Scandinavian countries the public health nurse often provides the patient with the first contact with health services for the rural areas. The public health nurse in Ireland fulfils many of the preven- tive and educational, as well as some of the control, roles of the physician. In the USSR the feldsher, trained for skills somewhere between a fully qualified nurse and a physician, provides a substantial amount of the primary health care in many rural areas. Yet in most European countries - and not only those studied here - the main initial contact for the diagnosis, treatment, and pre- vention of illness is the physician. All systems train and utilize some kind of general doctor who deals with the day-to-day complaints and problems and takes general care of the community around him. In eastern Europe there is a division of labour in such primary care between the general physicians, the paediatricians, and the occupational medicine practitioners. In the German- speaking countries individuals can go direct to a specialist, but in Denmark and the English-speaking countries referral to a specialist must be through a general practitioner. The majority of countries experience difficulties in obtaining physicians for their rural areas. Most use inducement payments, loans, housing, and the like to encourage practitioners to establish themselves in more remote areas, and sometimes create barriers to practice in favoured areas. Questions of quality control, including further education, are being raised now. The primary care physicians in the German-speaking countries, in Denmark, in Ireland, and in Scotland are independent contractors. Each doctor providing primary care in these countries is obliged to negotiate an individual contract with the paying authority, whether the state or an insurance fund . There is little supervision of primary care physicians in western European countries. Thus, when they have initially satisfied the authorities of their competence, there is little othe r than the judgement of the patients themselves to ensure that they exercise a particular level of skill or provide a particular quality of service. As long as a practitioner does not commit any obvious or gross error, it is unlikely that the patient will have the means of judging his competence. Continuing education is not always obligatory, and the degree of participation in educational schemes varies substantially among the various physicians. In the eastern European countries physicians are salaried and sub- jected to stricter supervison both administratively and educationally. It will come as no surprise that priority is given to the hospital service in all the countries studied. More thought, time , effort, and financing have been given to hospitals than to any other part of the health services. In eastern Europe the establishment and attainment of norms for hospital beds seem to be a priority in the national plan, and the number of hospital beds per unit of population tends to be higher than in western European countries. Scotland is at the other end of the spectrum; there special efforts are being made to reduce the need for acute hospital beds, as an agreed policy. Both in eastern and in western Europe there has been a tendency towards concentrating hospital beds in large units in order to give the population the benefit of more specialized medical care as well as to close down less efficient peripheral institutions. It seems, however, to be a constant feature that local communities in all countries resist institutional change, for people do not like losing their local institutions. The more depersonalized atmosphere in central institutions, the increased 9 problem of transport to them, pride in local institutions, and the assurance of local employment are arguments often mentioned in support oflocal units. In most of the countries studied , except the German-speaking ones, hos- pitals provide both inpatient and outpatient care. Part of the considerable dif- ferences in the ratio of hospital beds to population in the various European countries may be explained by the difference in the availability of domiciliary services and nursing homes, sectors that have been developed most extensively in the Scandinavian countries. SOME PLANNING ISSUES Types of health planning Although some form of health planning has been going on for a long time - in Sweden hospital planning through the county councils has existed for over a hundred years - it is probably fair to say that the precursor of the more consistent, comprehensive type of planning within the health sector was national socioeconomic planning. Such planning became routine in the USSR following the establishment of the Republic, in order to ensure the desired socioeconomic development. This resulted in the system of 5-year economic development plans. This system, applied to health, has also become the rule in Hungary. The plan specifies in great detail the targets to be reached, the ap- proaches to be used, and the resources to be allocated to all parts of the health services. Following the Second World War, economic plans were developed to bring about economic stability in Austria, in the Federal Republic of Germany, and to a lesser extent in Denmark and Scotland, and health planning automatically became part of such planning, though not to the same extent, with such links and in such detail , as in eastern Europe. In the western European countries health planning has been, by contrast with that in the east, sporadic and disjointed. It was only in the 1960s, and more so in the 1970s, that comprehensive planning systems for the health sec- tors started to develop .- The hospital sector tended always to be the first area for which suc;1 planning systems were created, reflecting the considerable resources allotted by society to that sector. When planning started in Sweden and later in Austria, Denmark, and the Federal Republic of Germany (at the end of the 1960s and the beginning of the 1970s), it soon became apparent that hospital planning alone was not sufficient to provide a balanced develop- ment of the health services , and the necessary coordination with socioecon- omic planning in general had to be put in hand. In Denmark in particular several new laws and regulations have been adopted recently to ensure the development of planning for parts of the economy bearing on health other than those directly concerned with health services. So far, however, no western European country has developed a fully comprehensive health planning system including environmental and occupational health, although in Scotland, as part 10 of the United Kingdom, health policy has moved towards the incorporation of most of the domestic (nonresidential) services to patients in the public system. Health planning methods In the eastern European countries health planning is formally more cen- tralized and relies heavily on norms and standards fixed at national level, on the basis of studies establishing the need for health services among the popula- tion, the productivity of health service units, etc . These norms and standards are applied to population forecasts and are especially comprehensive in the sense that they include specific estimates for different types of workers and other population groups with particular health service needs . In western Europe the elaboration of norms and standards has been less extensive, re- flecting a lesser degree of dirigisme. While some studies to determine need have been made for the health services, most of the planning has been on the basis of demand and of the allocation of resources to avoid obvious gaps. In Sweden, and to a somewhat lesser extent in Denmark, Ireland, and Scotland, central authorities provide guidelines and some norms for planning in support of their policies and intentions ; in Austria and in the Federal Republic of Germany this is done by the Lander. In Scotland an attempt has been made to apply the WHO-developed sys- tems analysis method called project systems analysis to the planning of child health services. Although the planning exercise was successful and demonstrated the value of the method, the plans were not fully implemented , mainly because of changes in the priorities governing the allocation of resources. While in Sweden an extensive system of health manpower planning has been elaborated with regard to the education of physicians, in the other western European countries studied there is little integration of health manpower planning into health services planning. Coordination between health planning and other types of planning In all the countries studied efforts are being made to coordinate health planning and socioeconomic planning in general, but the extent of the efforts varies considerably. In Sweden the central control of expenditure is somewhat limited because of the considerable independence of the counties, the number of new physicians being the only factor completely controlled centrally by the national government. In Scotland the estimated expenditure on hospitals and general medical services (primary care) is included annually in the public budget. This involves the central government to a larger extent than in the Scandinavian countries, and a large measure of central control over health expenditure is thus made possible. Less , however , is done with regard to manpower requirements ; accordingly, manpower control is an offshoot of budgetary control. Both in Austria and in Schleswig-Holstein hospital planning is carried out with an eye to the financial implications, and there is therefore a fairly strong link between health planning and economic planning. In the eastern European countries the general system of socioeconomic planning sets very strict and clear guidelines for allocations of resources to the 11 health services, in terms of capital investment, operating costs, and health man- power. In both Hungary and the USSR there is thus very close coordination between health planning and socioeconomic planning in general. In al1 the countries studied there is an increasing interest in land-use planning. This is particularly noticeable in Austria, Denmark, and Schleswig- Holstein, and it has long been a feature in Scottish planning. In the Scandinavian countries and in Scotland increasing attention is being given to the close relationship between social and health services, in particular in such areas as domiciliary care and nursing home services. In Denmark the new planning system for primary care applies equally to the social services, thus giving them due emphasis. In those countries where social services are provided by administrative units other than those in the health services, the planning systems are not well integrated . HEALTH SERVICES FINANCING Funding The most important key to control of the development of the health services is still finance. In all the countries studied the method invariably used is by yearly budge ts in which the contributions of the state (whether through taxation, the insurance system, or a combination of the two) and of local government are clearly specified. In eastern Europe there are in addition 5-yearly budge ts , which give fairly firm guidelines to the planners for the years ahead . In those countries too there are long-term projections for 15 years or so, which forecast some major items of expenditure. In western Europe long-term budgeting is the exception rather than the rule , although most countries make forward estimates for 3-year to 5-year periods. Since education, training, and building policies take many years to become actual programmes, forward planning has to be taken into account in fi- nancial policy. In some of the countries, mainly the eastern European ones , the central authorities review local budgets in considerable detail . In Sweden economic forecasts are made for several years ahead, and there are feedbacks from both the private and the public sector to enable adjustments to be made. The county councils, for example, submit various plans, and these are reviewed by the economic department of the Ministry of Finance to take into account infla- tion, both real and monetary. In Scotland, the central government provides a block grant to the Secretary of State for Scotland, who has other departments of state within his sphere of responsibility. In all countries conside rable attention is being given to equitable distribu- tion of services, and the central government tries to reduce differences by equalization grants of one kind or another. Denmark, Hungary, Ireland, and Scotland provide notable examples of this. Again this kind of forward planning is an important element in financial policy. 12 Less independent authority is given to each county or republic in Hungary or the USSR than to the Land, the Danish or Swedish county, or the Austrian province. The latter have power to levy taxes for health purposes, and they therefore have a larger measure of control over the disposal of their own rev- enue. There is, however, some provision for local funding in the eastern Euro- pean systems. In the USSR, for example, surplus funds from local industry and from ko/khozes can, under certain conditions, be used for strengthening the local health services. Because of accountability requirements, the control of total expenditure tends to be rather more strict in countries that rely heavily on central taxation, as do the eastern European countries, Ireland and Scotland. In countries where insurance schemes bear a larger part of the financial load, such as the Scandin- avian and German-speaking countries studied, there appear to be somewhat less immediate pressures to contain costs. It is noteworthy , however, that in eastern Europe there is some provision for local authorities to carry forward unex- pended balances into following years, as incentives and achievement bonuses. This is not so in Scotland. It is also of interest to note that in the USSR there are some experiments involving giving local officials opportunities to utilize funds for innovations and so to improve services. None of the eight countries has gone very far in developing programme planning and budgeting systems, although some experimenting is going on at lower levels in some, notably Sweden. Methods of payment for services Expenditure on hospital services is met through centrally approved budgets in the eastern European and English-speaking countries studied, mainly through local government in Scandinavia, and through health insurance funds and tax funds in the German-speaking countries. The method of payment of primary care physicians varies considerably among the countries studied. Like other workers in Hungary and the USSR, doctors work on a shift basis, are part of the state health service, and receive a salary for their work. Their channel of representation to the authorities is the medical trade unions. Primary care physicians in the western European countries are independent contractors. Each doctor in primary care in the German-speaking countries, Denmark, Ireland, and Scotland is obliged to negotiate an individual contract with the paying authority - either the state or the insurance funds. Doctors in the German-speaking countries negotiate with the ;nsurance funds through their local association branch, there being no direct contact between the funds and physicians. These branches are powerful organizations. In Austria and the Federal Republic of Germany payment to doctors is made by item of service. Each doctor is thus required to specify the diagnosis and the details of treat- ment for each patient. In Scotland, and to a lesser extent in Ireland, doctors are paid largely on a capitation basis, although certain other allowances and item-of-service pay- ments are paid additionally. The item-of-service pay men ts and allowances are , to a large extent, inducements , rewards , or compensatory payments for such 13 things as group practice, refresher courses, maternity care, and out-of-hours work. In Ireland and Scotland secondary or regional authorities funded by the central government negotiate such contracts with physicians, but the scales are centrally negotiated between the government and the medical unions. In Denmark the system of payment of physicians has recently changed and now includes a mixture of capitation and item-of-service payments. The national insurance board negotiates the average income level for physicians with the medical association at national and regional level , half being paid as a capita- tion fee and the rest by item of service. THE HEALTH INFORMATION SYSTEM AND HEALTH SERVlCES RESEARCH AS A BASIS FOR DEVELOPMENT Reliable information on health problems and health service activities and research on new and better ways of solving health problems are prerequisites for good health services. Interesting developments are taking place in both these areas within the countries under study, but much remains to be done. Health information systems The health information systems show considerable variation among the eight countries. All collect and disseminate information about births, deaths, causes of death , and infant and perinatal mortality. Some have exten- sive registries for specific diseases such as cancer, and information is generally available about certain infectious diseases , vaccination for communicable diseases, etc. The countries of eastern Europe tend to have more information collected about all kinds and episodes of disease than countries in western Europe have. Most countries have basic statistical information about hospital inpatients, including bed utilization and diagnostic categories, and mortality and mor- bidity data. In eastern Europe information is available about outpatient services and primary care services , reflecting the comprehensiveness of services there. Such informat ion is often lacking in many countries in western Europe, and the lack represents a serious impediment to the planning and evaluation of such services. Information is also scarce in these countries about treatment regimes for patients, diagnostic procedures, etc. This is surprising, since such informa- tion is of much potential value in planning. The major problem is, of course, that of gaining access to it. In the German-speaking countries, for instance, considerable information is stored in health insurance offices and in the medi- cal association branches, but it is not available to the health service administra- tion responsible for planning and evaluation. There is a similar scarcity of information about preventive services, in particular with regard to the environment. The health services administration often lacks information from other agencies about their environmental pro- tection activities. 14 With the development of national and regional policies for health services (even where medical care is provided commercially or by charity), countries are discovering the necessity to develop more complete systems of information- gathering. It is now being recognized that much illness occurs outside hospitals and attention is increasingly focused on the need to secure data for the popula- tion at large. Studies seeking to match health resources with health needs in population groups are attracting more interest. There are a number of studies of this kind at present, notably in the USSR. Parallel efforts are being made in data-handling. The present stage is, however, one of development. Several countries are experimenting with the use of computers in health information systems. The Scandinavian countries have had computer systems covering hospital admissions for a considerable time. Sweden in particular is well ahead of most other countries in developing a population-based health register. The protection of confidential data in such computer systems is a universally controversial issue. The extensive security measures introduced into the Swedish system may be a useful guide, since they seem to provide reasonable assurance that sufficient means exist to safeguard information gathered for clinical or administrative purposes from abuses. Indeed, the specific use of the information being collected is a key policy matter. The term "statistics" is now wholly inadequate without an indication of the specific uses to which they will be put for clinical, planning, evaluation, or epidemiological surveillance purposes. This poses questions about the information that should be collected and at what level. The linkage of data and their place in the total clinical and planning system are clearly subjects for further study. Health services research It is relevant to the whole question of information systems that there seems to be a general recognition in most European countries, in western Europe in particular, that a more critical analysis is needed of health services activities and of what they achieve. Although considerable scientific advances have been made within the health field in recent years, the question has been raised whether the benefits obtained from them justify the cost and whether other fundamental and widespread health problems have been neglected through inadequate primary care and preventive services and inadequate control of the environment. There seems to be a growing feeling that, while health will always have a high priority, health services will not necessarily rid countries of diseases and resources for health services cannot be limitless. As a con- sequence, the question of the cost-benefit and cost-effectiveness of health services has begun to be raised to a greater degree than before, not just among health officials but also among the public at large. The question has been made more urgent by the rapid growth in the total cost of services on the one hand and the worldwide economic recession on the other. It is this trend which has led to a rapidly growing interest in health services research as distinct from clinically-oriented medical research. Considerable funds have been made available for such research in many countries, and it is an interesting common feature that such funds are being administered through 15 the ministries of health, which have been actively involved in such research through the promotion and funding of studies rather than through the tradi- tional channels of scientific research funds, the research councils. This develop- ment is reflected in the creation of special health services research institutes such as the Semasko Institute in the USSR, the National Institute for the Planning and Rationalization of Health and Social Welfare Services (SPRI) in Sweden, and the Danish Hospital Research Institute. At the same time, a greater interest in health services research has been stimulated in the universities and in the traditional research institutes. Much remains to be done to improve the various techniques necessary, but the trend is unmistakably towards closer coordination and cooperation among the education, research , and health service sectors, which will be mutually beneficial. The success of research policies could prove to be decisive in the quest for better health care in the European countries. * * * Health is a subject that crosses all manmade barriers, in that a great deal of knowledge is available through international comparative studies related to population characteristics and the communication of scientific discoveries in medicine throughout the world is almost instantaneous. Accordingly, it is not altogether surprising that, even allowing for different political systems, the organizational structures of the health services do not differ greatly through- out Europe. ft has long been recognized in the eastern European countries that health has to be related to the whole socioeconomic aspect of state planning. It now seems that a not dissimilar view is emerging in western European countries. It is perhaps inevitable that planning should be a more complex process in the mixed economic systems of western Europe, yet the ultimate problems of providing people in need with health services are markedly similar. This is especially so in periods of widespread economic recession such as now, when governments become more interventionist and priorities have to be established. Given the conditions of modern living it is perhaps not so remarkable that the scale of priorities, in each country the product of many strong internal forces, should follow a common pattern of change, although perhaps with differing time-scales. The sciences of demography and epidemiology reveal gaps in services and give rise to general public policies and priorities ; these are modified to deal with local problems instantly recognizable as similar both in eastern and in western Europe. The universal problem is one of mobilizing knowledge, technology, capital development, and manpower to alleviate the burden of morbidity. The more the problem is illuminated by cross-national comparisons, the more likely it is that the sum of knowledge about a wide range of health and health-related problems will be increased. If sometimes the problems seem in certain places to be almost intractable, the curiosity stimulated by knowledge that they are not so in others is a powerful factor in social and political action. 16 Health services research indicates the historic inevitability in all countries of the iterative process of health planning with its successive cyclical stages of analysis of the current situation, formulation of objectives, evaluation of op- tions, operational implementation, and post hoc evaluation of such operations. Policies to achieve social aims such as equity of individual treatment or redis- tribution through resource allocation, priority-fixing in all senses, and even such self-correcting mechanisms as monitoring for accountability can be fitted into any section of the cyclical model , as can attempts to tackle the conceptual problems at the heart of both operational and political practice and develop- ment. The essential question is how in any society, whatever its basis, matters can best be arranged to reduce human suffering by optimizing all the humani- tarian and caring efforts and goodwill in the health services. The common aim is to safeguard the health of individuals through a health policy providing an assurance of reasonable equity as well as of a minimum standard and quality of services. The WHO Constitution proclaims that health is a right, and WHO plays an important part in aiding Member States to develop policies to achieve the com- mon goals. The dissemination of knowledge about technological and scientific developments in medicine is itself an assurance that standards of therapy and care are likely to improve universally. The economic advances and the resultant increase in the wealth of nations that have marked the post-war period have also ensured the existence of substantial resources for the application of the results of advances in scientific and technological knowledge at this crucial period in social progress. It has become almost universally standard practice to place special emphasis on better organization, so as to facilitate the effective deployment of resources. Consequently planning techniques to achieve the major objectives are in a constant state of review and development. Com- parative studies such as this on the health services of a number of European countries can contribute greatly to the generation of new knowledge. 17 I SCOTLAND* D.H.S. Griffith 1 & H.F.K. Zo"flner2 Scotland is part of the United Kingdom of Great Britain and Northern Ireland, but differs from the other parts of the United Kingdom in certain significant respects; for example, it has its own legal system, and the health and education systems are administered by the Scottish Office. The Minister with major responsibility for the management of Scottish affairs - the Secre- tary of State for Scotland - is a member of the Government of the United Kingdom. Scottish Members of Parliament are elected to Westminster and par- ticipate in all parliamentary activities. While Scotland has its own central departments for some of its own affairs, it shares with the rest of the United Kingdom a number of ministries and na- tionalized industrial concerns. Examples of these are the Inland Revenue ( there is no separate power to raise taxes in Scotland) and the Ministry of Defence. Nationalized concerns include the National Coal Board and the British Steel Corporation. Scotland has suffered from the effects of the economic recession. It also suffers from a number of economic handicaps, such as the presence of old and no longer competitive industries and problems of mobility of the work force. Parts of Scotland, mainly the west central area, are indeed among the most deprived in the whole of the United Kingdom. This socioeconomic situation. is also reflected in the demographic picture. The population is an aging orte, partly because of the emigration of younger persons but also because of a con- tinuing fall in the birth rate. Interestingly, the crude death rate over the past few years has remJ.ined almost static. * While the Government of the United Kingdom has agreed to the publication of this report, it does not necessarily agree with all the views expressed therein. 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Copenhagen, Denmark . 2 Health Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 19 THE FUNDAMENTALS Of PLANNING IN SCOTLAND Scotland has been passing through a major phase in its development. The former local authorities have been reorganized into larger "regional" and "dis- trict" units. The new organization has been in existence since May 1975. The reduction of local government authorities from 430 to 64 has obviously not come about without some difficulties. It is against this background that both overall planning and health planning are now taking place. Planning in Scotland takes into account not only government services and industries but also an independent private sector. It may range from the alloca- tion and investment of major resources to the siting of a small business or workshop. No single legal instrument lays down every term and condition stating what shall be done by whom and when. However, because the aim of the planning is to improve the quality of life of the population and because the resources required for this purpose must come largely from public funds, it is not surprising to find, as part of the Scottish Office, two departments con- cerned with development and economic planning. Planning in Scotland in the past was largely concerned with land use, with the growth, resiting, or closing down of industries. At present, according to the report of the Royal Commission on Local Government, 1966-69 (pages 58 and 59), planning should include : "intelligence" (i.e., information), economic planning, land-use planning and the implementing of services. The same docu- ment continues (page 6 I): "It is helpful to think of the activity of planning in terms of a series of circles of decreasing size, the largest totally enclosing the next in size, and so on. Nationa! 0 plans have to be devised in the light of national economic objectives. This in turn sets the fran1e for area plans within Scotland and so on. Each of these stages, in our view. should be the responsi- bility of a separate layer of government, whether central or local . Of course, planning is a continuous process, and in the formation of plans there is, or ought to be, a great deal of consultation both "upwards" and "downwards": but the duty of planning at a particular level , within the limits set by the plan immediately above, should rest unambiguously with the organ of gove rnment at that level ". Overall planning therefore takes place at the central level. At that level most of it is concerned with coordination and the preparation of guidelines. However, because of the recognition that some areas suffer from greater social and economic deprivation than others, the allocation of certain public funds is controlled from the centre. For example, a number of areas in the United Kingdom that have suffered from decaying industry, poor housing, and severe unemployment have been designated as "development areas". The most severely depressed of these have been classed as "special development areas". Among the latter in Scotland are the areas in and around Glasgow, the new towns, and part of the Fife region in the east of Scotland - in all, more than half the total population. The rest of Scotland is classified as a "development area". It is to a Unless otherwise stated "national" should be taken to refer to Scotland only . 20 the severely depressed areas that most central financial assistance will be given, including loans to selected industries. It is contemplated that the Government will also provide funds to demolish older industries and introduce new ones ; in other words, it is intended that the Government should change the industrial and social infrastructure through both public and private incentives. In the long run the Government may well buy itself into private enterprises by purchasing shares in them. Forecasts are not normally published except for a budgetary statement. However, forecasts have been prepared and issued to regions. It is expected that a series of "regional'' plans will be dovetailed by the central authority over periods of 5 to IO years or even longer. On the financial and economic side it is anticipated that 5-year " rolling" programmes will be prepared , linked, of course , to the physical plans. The main planning organs are the newly organized local authorities. The regions, of which there are nine, are responsible for strategic planning and for the provision of some services , including such functions as education , social services, transport, roads , police , water , and sewerage as well as the develop- ment of industry, land use , and other infrastructural matters. Island authorities , of which there are three , serve small populations and undertake strategic and local planning. The planning done by districts, called local planning, relates to the services provided by the district councils and includes housing, environ- mental health, recreational amenities, and libraries. (Districts may be loosely equated with what elsewhere would be called municipalities.)0 It will be the duty of all local authorities first to produce a stocktaking of their present position and subsequently to prepare plans at the appropriate level, aided in their proposals and forecasting by the various central instruments of government. In all, three types of report will be called for: (a) regional, (b) structure plan, (c) local plan. Regional reports are not mandatory but set the scene. The other two types are statutory. However , no local plan is ac- cepted until it is seen to fit into the structure plan for the area . All regions and districts have elected councils served by permanent officials appointed by them. Funds come partly from a property tax (rates) and partly from a government grant (approximately in the ratio 30 : 70). Regional planning forms an important link between central and district planning in Scotland. The country is very diverse in its topographical character, but studies have shown clearly that Strathclyde in the west of Scotland is the region that suffers from the greatest social deprivation . It contains about half the total population of Scotland and consists of densely populated urban areas, rural areas, and sparsely populated islands. The problems of the area were highlighted recently on completion of the analysis of the 1971 census. The main problem is that of the concentration of a The general criteria for delineating regions or districts include su ch factors as popu- lation, travel to and from work, nodal grouping of facilities , education , medical and health care, shops, stores and banks, electrical supply, employment, recreation , and local news- papers. 21 low-income groups in large housing estates where 80% of the houses are pro- vided by local authorities. It has become clear that it is here that multiple deprivation mainly exists. The problems arising include unemployment , low incomes, overcrowding, single-parent families, low educational attainment, and high long-term probation rates (of individuals who have committed misde- meanours and are under obligation to report regularly to an adviser appointed by a court of law). Suggested solutions now under discussion are: (a) improved information so that unemployed persons can learn about jobs and, where necessary, be retrained in other skills - present employment centres are too centralized and should be more available locally; (b) early intervention by intensive day care for preschool children, with more help and advice for mothers ; (c) closer contacts between education, police, housing, and social work departments at all levels; (cf) improvement rather than replacement of existing houses, thus keeping the people in an area with which they are familiar. Work has already started in two pilot areas in Motherwell (in Strathclyde), where the central, regional, and district authorities are working together. In each case the area has a population of about 5000 persons. The areas are now conducting surveys, advertising jobs, and forming community organizations. The · provision of health centres by the health boards in these localities could be expected to have a powerful catalytic effect on the provision ofhealth and other services. However, the provision of health centres depends to some extent on the agreement of medical practitioners, who in some instances may prefer to work on their own. In addition, there are fewer social workers than medical practitioners. The initiative is, however , being taken by district medical officers, who are now establishing contact with various bodies in their districts and encouraging the use of social workers in health centres. Relationship between development and health planning On the face of it, there seems to be little connexion between development and health planning. However, a major aim of planning is the improvement of those areas most seriously depressed socially. This will have a distinct and sig- nificant effect on health status. Furthermore, any improvement in the economic situation will inevitably make more funds available for direct expenditure on health. Since development planning is connected with land use and with other criteria, it is obvious that the location of health facilities and personnel should be a matter for close consultation between planners for both development and health . The location of a health centre is , for example, of considerable import- ance as a nucleus around which other community planning can take place. Finally it must be noted that local authorities have statutory duties with regard to the provision of environmental care, housing care for various needy and handicapped groups, and different social services. All these have a distinct and direct bearing on health. 22 NATIONAL HEALTH SERVICE IN SCOTLAND The National Health Service in the United Kingdom, like local govern- ment, has recently undergone a major reorganization. In place of regional hospital boards, executive councils for the general medical, dental, pharma- ceutical and ophthalmic services, and local authority public health depart- ments, 15 health boards have become responsible to the Secretary of State for Scotland for the administration of all parts of the health service on an inte- grated basis. In some cases the areas administered are subdivided for manage- ment purposes into districts. The Secretary of State for Scotland is responsible for the provision of the health service for the country. He is advised by the Scottish Health Service Planning Council, which consists of a chairman and 6 senior officers of the Scottish Home and Health Department appointed by the Secretary of State and a representative from each of the I 5 health boards and from each university with a medical school ( of which there are 4). The Council's secretariat is closely linked with the Scottish Health Service Planning Unit (page 25). To- gether they form a key group within the Scottish Home and Health Depart- ment. They are linked on the one hand with divisions of the Department re- sponsible for specific subjects (e.g., the care of the elderly), and on the other hand with a number of committees and working groups set up to give profes- sional advice and study specific problems. In addition, the Central Health Ser- vice Planning Unit, among others, contributes to the work of a policy group that plays an important part in the coordination of advice on policy. This group is chaired by the Secretary of the Scottish Home and Health Depart- ment and its membership consists of the senior administrative and technical staff of the Department.0 Financing the National Health Service A major constraint on the development of the National Health Service is the cost. Almost all the funds for the National Health Service come from general taxes , e.g., income tax, customs and excise duties, and value-added tax, those from national insurance contributions being relatively negligible. Charges for medical prescriptions are more of a deterrent to frivolous requests for drugs than a real sourc, . of income. Within overriding United Kingdom policies, responsibility for the use of funds for the Scottish National Health Service rests with the Scottish Home and Health Department, acting on behalf of the Secretary of State. a The government service in the United Kingdom has been run on a dual system, one a professional lay administration, the other technical officers, doctors , nurses, etc., who advise rather than prepare alternative choices for political decisions. Today, this situation is changing; technical officers may now, in appropriate circumstances, carry out duties formerly confined to administrators. 23 Programmes of expenditures are drawn up on a 5-year basis, the present period ending in 197?-80. Because the Heal th Service offers services rather than goods, most of the current expenditure is on pay: 70% of all operational spending in hospitals is on salaries.0 It is unlikely that large changes will occur in the fore- seeable future in this system, which has become rather rigid and confining. In addition, the rate of growth is a matter for government decision. In the past there has been a real growth per annum of about 3½%. Re-evaluations are made to take account of rises in pay and prices. The annual estimates begin to be made around midsummer, based on projections and on ministerial policy, and the expenditure is usually approved by November. This forms the basis of the estimates submitted to Parliament. These, as adopted by Parliament with some possible alterations, become the budget for the following financial year (April - March). The distribution of funds from the Department has also taken on a fairly set pattern. Most of the funds have already been committed, so that the hands of the area or district administrator are already tied. The funds go directly to the health boards. Capital expenditure is kept separate from current expenditure. Major building works, which account for approximately 7% of all expenditure, are closely supe rvised by the central department. For smaller schemes and improve- ments, each board receives an allocation calculated on a population basis, and it has authority to use the allocation as it may decide itself. Authority for current expenditure is almost entirely delegated. Allocations to areas are not based solely on population, but take account of the existing pat- tern of services and of new developments in major new buildings. They also allow for the higher costs of the specialist city hospitals, which act as medical training centres and provide services for patients from rural areas or, in some specialties, for patients from a much wider area than the nonnal catchment areas. With the reorganization of the service a method of allocating revenue to the new health boards was needed that would ensure that each board would have sufficient funds at least to enable services to be maintained at their old level. The method used for the 1974- 75 allocation was as follows: Hospital revenue (a) pattern of previous year's allocation repeated (b) development money - about 3½% - added to previous year's alloca- tion, weighted to take account of increases in pay and prices (i) earmarked for revenue consequences of capital building pro- jects (about I% of the total) (ii) almost all the remainder allocated to boards on the basis of the number of beds, the types of case dealt with, and the types of outpatient {about 2½% of the total). a An important consideration in financing the Health Service is the independent con- tractor status of general practitioners and dentists. General practitioners are paid mainly on a capitation basis, dentists mainly on items of service. 24 Community revenue (a) previous year's allocation as taken over from local health author- ities (i.e., former counties and large burghs) (b) development money allocated on a population basis. The above method of allocation is being reconsidered in the light of ex- perience of the first year's work. No action has yet been taken to apply any programme or performance budgeting system. The Scottish Health Service Planning Unit The Scottish Health Service Planning Unit assists the Department's policy group to determine options, to formulate views, to resolve conflicts, and to make suggestions. rt has several other main functions : (a) to coordinate health service planning within the Scottish Home and Health Department (b) to give support to the Scottish Health Service Planning Council and its secretariat (c) to provide a link be tween the work of the central department and that of the Planning Council and the national consultative committees (d) to assist health boards on planning methods as required (e) to prepare appropriate planning and evaluation methodo logies (j) to organize, conduct and supervise in-depth planning studies as need be. In establishing the Planning Unit it was accepted that it should be small, multidisciplinary , consist partly of civil servants from the central department and partly of staff seconded from the National Health Service, and when neces- sary co-opt consultants with skills in systems analysis, operational research, and any other disciplines that would help to deal with problems in a way that field personnel can grasp. The unit itself consists at present of a director who combines administrative and medical responsibilities, two medical officers, two senior administrators , a nursing officer, and a small supporting staff. A number of operational research consultants have been working with the unit from time to time, but so far no other disciplines have been attached. Most of the activities detailed above are self-evident. Those concerned with the planning process , methodology, and in-depth studies deserve a description. In I 973 a mixed team of Scottish officials, including the director of the Planning Unit, joined with the World Health Organization to work out a planning methodology that would provide an example of how planning and programming could be carried out in a specific area , that chosen being child health services. The joint exercise, which involved the Department's research and intelligence unit (now the Information Services Division of the Common Services Agency), in many respects laid the foundation for further methodological development. It set standards for the collection of data that will be of lasting value in planning 25 and programming. In addition, it showed how a multidisciplinary group working together could combine diverse epidemiological, financial, and administrative data into one coherent whole. An important and little publicized activity of the Planning Unit has been a pilot review of the functioning of the health services, which may provide a systematic basis for Scottish planning for the future. As at present con- ceived, it will include sections on population, social and environmental condi- tions, health status, resources, resource utilization, and various constraints. Ten-year projections are proposed for several areas as well as a valuable analysis of present statistics and past trends. This useful work should certainly be of help in the future planning of the Scottish health services. A ge nuine effort is thus being made to devise a series of planned and, where possible, quantified aims and objectives that will provide better guidance for present and future policy makers. The Information Services Division of the Common Services Agency The Information Services Division (ISD) of the Common Services Agency has an important role in the provision of data for planning. It has the duty of collecting and disseminating information from the central level about the health services, and of encouraging the development of information services at health boards. The Division collects a wide range of data on resources, service utilization, and manpower. Data are aggregated from personal records and statistical sum- maries supplied by the 15 health boards. The personal records are those of hos- pital admissions and discharges ( demographic, diagnostic, and management items), school health examinations, cancer registrations and, more recently, abortions, as well as of all persons working in the National Health Service in Scotland. Information on hospital resources includes data on waiting lists and on bed occupancy and hospital stays. Information on community services includes data on child welfare, antenatal and postnatal clinics, immunization levels, dental services, and visits paid by community nurses. No data are available centrally on the workload in general practice, and outpatient data are restricted to the numbers of new attendances and the total attendance by specialty. New developments in these two areas are in- hibited by the lack of resources to increase the medical records staff. Ad hoc studies help to ti ll these gaps in the data: for example, a report on morbidity in general practice by the Office of Population Censuses and Surveys and the Royal College of General Practitioners, and an intensive study of outpatient consultations in selected specialties carried out by the Division. In addition to the routine collection of information the Division carries out ad hoc studies to assist in the Department's policy making and planning: for example, on acci- dent and emergency services. The Division puts out a number of publications annually, notably Scottish health statistics, but summarized data are also fed back to health boards, hospitals, and even individual clinicians and clinical divisions. This latter development is in tended to serve as a stimulus to the examination of perform- ance, although the data held at central level are restricted in relation to clinical 26 activities as opposed to resource utilization. The Division also operates an ad hoc service for supplying data on request, and considerable demands are made on it by the Department, the Planning Unit, programme planning groups set up to consider particular topics, and the health boards. The ISD is not a large division, considering the amount of material it processes. It has 3 physicians, 3 statisticians, 6 research staff members (social scientists) , and 4 computer experts. There are some 40 supporting personnel. Little work has yet been done on economic data in relation to health service management and resource use . This may well be because administrators still do not know what questions to ask of economists. However, the current period of financial stringency has the effect that more attention is being focused on the establishment of priorities in the allocation of resources. Progress in social work services The separate social work services in Scotland (the services for children, the elderly, the physically and mentally handicapped, and the mentally ill and the probation service) were unified into local authority social work ser- vices in 1969. Since that date local authorities have also undertaken to pro- vide social work services to penal establishments in Scotland. On the reorgan- ization of local government in 1975 the social work services were fully inte- grated when the health boards were required to transfer to the new regional councils the social workers until then employed in the health service. The regional councils became responsible for providing social work services to the health boards, and many of the social workers transferred still operate from hospital bases. The reasons for unification were stated by the Government at the time to be that the services had developed piecemeal, each seen as aiming at a dif- ferent kind of social problem, and that experience had shown that in many cases the situations in which social work help was needed were complicated, families being visited by a number of services often overlapping in their as- sistance. Social workers in the separate services agreed that basically they re- quired the same expertise , although specialized knowledge and experience were often also necessary. Moreover, the various services were competing for the limited numbers of trained staff available , the division of responsibility between services was an obstacle to the most effective and economical deploy- ment of staff, rnd many families were confused about which service to ap- proach and about referrals from one service to another. The transfer of responsibility to social work departments reflects the large amount of care of that kind needed within the community. Patients move into hospitals from the community where their social problems lie and, al- though they may still need help with social problems during their stay in hos- pital, in most cases they will return to the community and may or may not require continuing social and medical care. The social worker employed by the local authority has direct access to the resources of the local authority social work department in seeking to meet the social needs of patients re- ceiving care within the health service . Many doctors were understandably ap- prehensive lest the social work service previously available to them should in 27 any way be drastically changed or reduced. In many hospitals there was no provision for social work ; it is hoped that it will develop and that it will be pos- sible to build up services that will not only provide support to health profes- sionals directly in their treatment of their patients but will also make more ef- fective use of the personnel in dealing with social problems. These integrated social work services now provided by the local author- ities in Scotland are grad ually becoming better managed and better organized, but they remain chronically short of manpower and finance. The central department (Social Work Services Group of the Scottish Education Depart- ment) in 197 1 fonnally requested local authorities to prepare plans for the development of the social work seIVices over the next 6 years and provided them with information and guidelines to assist them in the formulation of the plans. Local authorities have produced the plans as requested. It is apparent that much was left undone in the past , but a considerable step forward has been made by the creation of a proper infrastructure for the provision of social work services in both the statutory and the voluntary sector. Funds have increased by 70% since 1969 and the total number of social workers has doubled. A useful study bringing together information about the population, the incidence of mental and physical handicap , the numbers of children on proba- tion , etc., has already assisted in the assessment both centrally and locally of the numbers of social work services staff required. In addition, other broader studies are being undertaken , for example on the existing and proposed pro- vision for the elderly, including numbers of hospital beds, places in residential homes, and numbers of sheltered houses. A committee is preparing proposals for a more effective information sys- tem, which is expected to include such data as the frequency with which children in care are moved from one home to another. It will also combine information about staff movements and staff utilization . Local authorities are conducting individual studies about requirements in their own areas. The government Social Work Services Group has provided a useful lead to local services by stimulating and organizing the planning of development in the social work field. The contribution of voluntary seIVices is recognized as being particularly important in the field of child care and services for the blind and deaf and the physically and mentally handicapped, and local authorities were asked to take particular account of these voluntary services and their contri- bution in the development plan. Studies on the cost-effectiveness of different types of care are still needed, and on how to determine the best balance between geriatric hospitals, residential homes , and sheltered housing on the basis o f mutually acceptable admission criteria and recognition of the different needs of individuals requiring care. Work was about to begin using trained research workers along with unskilled staff in carrying out interviews in one area. Training is now organized by a Central Council for Education and Training in Social Work, which is a United Kingdom body with a Scottish advisory committee. Courses of training of different lengths are provided at colleges and universities and both in-service and advanced training in various methods of work or specialist needs are also available. 28 In general, the social work services appear to be settling down well. All local authorities are beginning to operate on the basis of similar concepts of social work ; broad staff/population ratios have been made known as at least interim targets ; there is now one statutory council for the United Kingdom on training; new training programmes have been worked out and are being de- veloped ; and liaison between health boards and various other statutory services such as education is improving, although staff shortages will unfortunately continue for some time. A wide range of other developments are part of the whole process of establishing an adequate professional service to meet social need in Scotland . Medical manpower In 1973 there were approximately 1.4 doctors per 1000 population. There has been a steady annual increase from 1964 onwards, with the exception of 1966 and 1968. The 1973 figure is 16.6% higher than that of 1964. Growth has been mainly in the hospital services, with Jess change in the number of general practitioners. Estimates are made each year of the number of senior registrars required to fill anticipated vacancies in the consultant establishment. Allowance is made for an annual expansion, of about 3% in recent years . The estimates go to uni- versity authorities and to the health boards and, on the basis of discussion with them, the number of senior registrars and, hence, of future consultants is decided. The period of service for junior staff is approximately I year as junior house officer , l year as senior house officer, 2 years as registrar, and 4 years as senior registrar. A special review is made of senior registrars entering their fifth and further years in the grade.0 It is the fourth-year registrar who is most likely to move on to a consultancy. Two other developments have taken place in policy. First , after 1979 all doctors contemplating a career in general practice will be required to complete 2 years of postgraduate training in hospital after the initial internship year and I year as an assistant in general practice. They will also be expected to pass the examination for membership of the Royal College of General Practitioners. Secondly, intending community medicine specialists will be required to go through registrar and senior registrar grades and will then be eligible to sit for membership of the Faculty of Community Medicine. This specialty will replace that of public health. Nursing The total number of nurses has risen steadily since 1964. In 1973 it showed an increase of 43% over 1964, largely because of the employment of more part-time staff, which now account for more than a third of the total a Most overseas staff entering the National Health Service tend to join as senior house officers and leave at the end of the registrar level. 29 hospital nursing staff. The number of qualified nurses has grown steadily, largely owing to the increase in the number of "enrolled" nurses. There has also been a steady increase in the number of unqualified nurses (nursing assistants). In 1968, however, it was noted that the recruitment of nurses aiming to become fully qualified had begun to drop. This set in train an investigation first of hospital nurses and then of all community nurses, taking into account such matters as marriage, full-time or part-time work, nationality, travel, families, and hours of work. These studies have been followed by a I-year review of entrants and leavers to show movements in the profession. It appears that 44% of nurses below the age of 25 years leave the service. Usually they have just completed training. Most reasons for leaving seem to be domestic (57% of all cases). Another nursing area where there is loss is that of mental deficiency, where large numbers of nurses are reaching retirement age. Efforts are now being made to create a manpower model with which it is hoped to provide more accurate staffing forecasts. Meanwhile, as mentioned earlier, enrolled nurses and nursing assistants have been employed in larger numbers, not only in hospitals but also to some extent in community nursing. Institutions related to central and peripheral agencies One other central agency not yet mentioned is the Common Services Agency, which has certain functions that can be most effectively undertaken on a Scottish rather than an area basis. They include information services, blood transfusion, and ambulance services. There are also a substantial number of important bodies which, although not a part of the National Health Service, nevertheless exercise an important influence on the provision of health care. Some are concerned with medical education and with primary and postgraduate medical qualifications. Others are voluntary bodies or associations representing health service staff either as professional bodies or as trade unions. The General Medical Council is a body established by statute which has a duty to maintain a register of all medical practitioners. It exercises an im- portant influence in safeguarding standards of medical education throughout the United Kingdom. The four Scottish medical schools (in the universities of Aberdeen, Dun- dee, Edinburgh, and Glasgow) undertake all undergraduate medical and dental education in Scotland and also a certain amount of postgraduate education. The Royal Colleges and Faculties have an important role in postgraduate medi- cal education and the qualification they provide is generally recognized as a prerequisite to specialist status. There are no formal arrangements in the United Kingdom for the registration of specialists, but upon successful com- pletion of the appropriate examination doctors become members or fellows of one of the Royal Colleges. Applicants for appointments as consultants in the National Health Service are usually expected to hold the appropriate quali- fication from a College. Among the voluntary bodies that have an influence on the provision of health care, the British Red Cross Society and the Women's Royal Voluntary 30 Service are good examples of traditional bodies with a broad spectrum of in- terest. In some instances, but by no means generally , voluntary bodies receive support from public funds. There is an important group of professional associations that exist to safeguard and further the interests of its members . The British Medical Associa- tion, the British Dental Association, and the Royal College of Nursing are im- portant examples of such bodies . Other health professions may be represented by trade unions such as the National Association of Local Government Em- ployees, the National Union of Public Employees, and the Confederation of Health Service Employees. On the nursing side developments have been rapid. A degree course in nursing is now granted by Edinburgh University and the Dundee College of Technology. The profession itself has been placed - certainly in the adminis- trative sense - on a footing comparable with that of the medical profession. It has also developed a number of ancillary groups whose objective is support for the fully professional nurse or nurse/midwife. Standards for other health professions are also continuing to rise, as a result not only of raised educational requirements but also of responsible and in- formed pressure from the various unions and professional associations. Health boards The Secretary of State has delegated to the health boards responsibility for the management of health services in their areas. They are semi-autonomous, in that they are not directly under the control of the Scottish Home and Health Department. Each health board is generally expected to prepare its own plans according to its interpretation of the needs of its own population, and to allocate its resources as it feels proper. Naturally there is constant communication be- tween the boards and the Department , but each board has every opportunity to conduct its own planning in the context of national overall guidelines. Each health board consists of a chairman and a group of members ap- pointed by the Secretary of State on the basis of nominations received from local government, trade unions, persons representing health service staff, universities, and other interested bodies. The size of the board varies according to the population served. The day-to -day business of management and the planning of care rest with the senior e, fficers of the board operating as an area executive group. This consists of a secretary or senior administrator, a treasurer , a chief administra- tive medical officer, and a chief area nursing officer. This group is corporately responsible to the board for the planning and day-to-day management of the service, but, apart from the group's corporate responsibility, each member has his own professional responsibility. The chief administrative medical officer is responsible for the general coordination of health care planning and is head of the team of specialists in community medicine . The chief area nursing offi- cer is responsible for the management of all nursing staff in the area; the treasurer for the management of all financial services ; and the secretary, in addition to coordinating the area executive group, manages the administrative services in the area. 31 Each health board has in addition a number of professional officials responsible for the management and organization of different services, for example , pharmacy services and catering services. A new group of physicians has been created - community medicine specialists (CMS).0 A typical distribution of their work is (a) acute care; (b) longer-term care; (c) maternal and child health care ;(d) environmental health ; (e) manpower; (J) development; (g) laboratory services; (h) mental health. They may prepare information and undertake work for the different subcommittees of the board, e.g., manpower, policy and planning, and programme planning. On the environmental side, medical officers selected by the health board advise the local authorities within the board area on the various environmental problems that arise. The community medicine specialist personnel work in conjunction with other officers and frequently collaborate in multidisciplinary teams for the purposes mentioned above. Depending on its size, an area may be subdivided for management pur- poses into districts. Districts have a management group called a district execu- tive group, consisting of an administrator, a finance officer (district treasurer), a district medical officer, and a district nursing officer. They are aided by, among others, a number of community medicine specialists. Like the area executive group, from which it derives its authority and to which it is ac- countable, the district executive group has a corporate responsibility . In their professional capacities the district officers are on the staff of and responsible to the corresponding district councils. The executive group coordinates and to some extent controls the community health personnel within the district as well as the hospitals under their care, but it does not exercise authority over general practitioners. Some of the smaller areas are not subdivided into districts , so that the area and district management functions are merged into one admin- istration. For example, the Border area, which has a relatively small popula- tion, is not divided into districts, whereas the Greater Glasgow area, which is the most populous of all, is divided into five districts. Within this organization the general medical and dental practitioners , pharmacists, and opticians continue to operate under the same terms and con- ditions as before, i.e., as independent contractors. Matters relating to their contracts are now, however, the responsibility of health boards and not , as in the past, of the executive councils that were concerned solely with these in- dependent contractor services. To advise the department , the health boards , and the districts, various health professions have set up national, area, and sometimes district consultative 0 " ... The function of the specialist in community medicine is to investigate and assess the needs of the population so that priorities may be established for the promotion of health, the prevention of disease and the provision of medical care. The specialty is also concerned with coordinating medical expertise so that policies which are in accord with medical need can be presented to the central Department, area health authorities and those responsible for the management of services below area level." In : Health services in Scotland. Report for 1974. London and Edinburgh, Her Majesty's Stat ionery Office, 1975 (cmnd 6052) . 32 committees,0 to which questions from the three levels are referred. In addition, a number of working groups or programme planning committees of mixed disciplines have been established by health boards to examine multidisciplinary questions and matters of policy relating to particular services to population groups such as the elderly or children. As a further aid to consultation, "divisions" of particular medical special- ties appoint members to district medical committees, on which hospital doctors and general practitioners are usually represented in approximately equal num- bers. These committees contribute to the membership of similar committees at area level. The latter nominate general practitioners and consultants to serve in the national consultative committee, which also derives part of its membership directly from universities and the various specialist colleges and faculties. THE GREATER GLASGOW HEALTH BOARD The structure and functioning of health boards have been discussed above in general. Glasgow, which will now be considered in detail, is a most important example of a heavily industrialized and physically and socially deprived area, containing about 20% of the total population of Scotland. As in other areas, the responsible authority is a Board of 23 members and a chairman, all appointed by the Secretary of State. The Board is a mixed one and includes persons nominated by local government, trade unions, universities, staff organizations, and other interested bodies. It is given wide powers in the conduct of its own affairs, except in so far as central guidelines are necessary, e.g., for national terms and conditions of service.b The structure of the different groups and committees can be seen from Fig. l and 2. It can be seen that the Board embraces all health services. The overall operation of the Board is conducted through the Area Execu- tive Group, which consists of the Secretary, the Treasurer, the Chief Admin- istrative Medical Officer (CAMO) and the Chief Administrative Nursing Officer (CANO). They, and the various committees, are aided and advised, for example on the medical side by a number of community medicine specialists, including statisticians, environmentalists , and child care specialists. This grouping is a So far there are medical, nursing, dental, paramedical (therapeutic), pharmaceutical, ophthalmic, and scientific committees. They may also appoint subcommittees of various specialist groups. It should be noted that these committees are not hierarchical. b The board is subject to certain restrictions on the use or otherwise of facilities. It can open or close a hospital ward. It cannot, however, make a major change in the pro- vision of facilities, such as the closure of a hospital, without the approval of the Secretary of State. It is also subject to restrictions in reserving sums for building ; the allocations for large projects are decided by the Secretary of State. However, an annual allocation to each health board allows it to undertake smaller building projects on its own account. 33 Fig. I. Relation of Greater Glasgow Healt h Board to the Health Servicea Local ---Health Northern I Council Public Secretary of State Scottish Home H and Health Department >--- Greater Glasgow r Health Board I Area Executive Group ~ I District Executive Groups Eastern I Western I South- Corpora te MANAGEMENT eastern Planning ~ National Council consultative committees Common Services Agency No formal links Area consultative committees No formal links ---- District South - consultative western committees Professional ADVICE a By courtesy of the Chief Administrative Medical Officer, Glasgow, and others. shown in Fig. 3, which also shows the relationships between the Health Board's specialists and those of the central Department in Edinburgh. With the integration of health services and the reorganization of local authorities, a number of problems have been posed for the specialist assigned to local authorities as adviser on environmental control. He is no longer a mem- ber of the staff of the local authority. Whereas in the past he was able to move freely within his own area, he now acts at the invitation of the appropriate local authority officer. Finally, he has no right as such to attend meetings of local environmental committees. The information service requires much building up. However, more data are said to be forthcoming through new and improved forms for hospital resource-utilization data. Other areas requiring investigation are the use of transport, managerial and utilization data, ward management , and data on out- patients and on general practitioner records. 34 Fig. 2. Committee structure in the Greater Glasgow Health Board 8 Greater Glasgow Health Board (23) I I I Manpower Policy and Finance and Committee (13) Planning General Purposes Committee (16) Committee (9) Fire Programme Precautions planning (3) committees: Child health Dental health Geriatrics Maternity Mental health Primary care etc. Note: the figures in parentheses indicate the number of members. I General practitioners committees: Medical Dental Pharmaceutical 5 Board members 4 General practitioners I Ser vice ittees : comm (Campi aints against individu al oners) practiti 4 Board members I 3 Genera practiti oners a By courtesy of the Chief Administrative Medical Officer, Glasgow, and others . The maintenance of a complete information system is also greatly hindered by the fact that the present National Health Service personal number does not lend itself to easy computer application , consisting as it does of digits, letters, and obliques. Studies are at present under way in health centres on the various reasons for calling a doctor. Hospital staffing ratios and "staffed beds" are also under scrutiny. An example of a 3-dimensional model for various groups, services, and support is given in Fig. 4 and 5. The Greater Glasgow South-Eastern District Executive Group The Health Board is divided into five districts , one of which is the south- eastern district. The district has no lay management body. It is administered by a district executive group consisting of an administrator, a medical officer , a nursing of- ficer, and a finance officer, who are responsible to the Area Executive Group 35 Fig. 3. Services of the Greater Glasgow Health Board SCOTTISH HOME AND HEALTH DEPARTMENT SERVICES 1------- PMO I 1-- --PMO ( PMO \ PMO Maternity and chi ld hea lt h Environmental Scientif ic suppart \ 1------PMO services COMMON SERVICES AGENCY SERVICES PMO • Pr1nc1p,l Med1 Co1I Olf1cer CAMO • Chief Adm1n1strat1vt' Med ical Ofl 1ce1 ems • community med1cme spec,ahst Development of services of the Board for all district services . The Board in turn furnishes various direc- tives, policies, and other advice through its various specialists and committees and its Executive Group.° Fig. 6 shows a proposed management structure that takes account of the administration, nursing , and finance hierarchies but omits the medical element. a The authors of this survey detected a certain degree of frustration among members of the District Executive Group, who are naturally impatient to manage , to plan, and to take action but who are apparently not receiving all the data they would like . On the other hand, the Health Board prefers the District Group to concentrate more on day-to~ay management, as it is unable to take an overall view of the whole area. 36 Fig. 4. National Heal th Service: 3-<limensional modela a By courtesy of the Chief Administrative Medical Officer, Glasgow, and others. The managerial aspects of the district services , e.g., staff recruitment, per- sonnel relationships, finance, and supply, are dealt with hierarchically from district to individual units. Recently a personnel officer was engaged and he is working closely with a nursing officer responsible for nursing personnel. The nursing group also belongs to a district hierarchy, posts being filled at the various levels by staff of varying seniority under the overall control of the district nursing officer. A community medicine specialist at district level is, however , in a non- hierarchical position in relation both to the district medical officer and to all other physicians in the area, except that his work is coordinated by the Chief Administrative Medical Officer. Consultants and general practitioners are not hierarchically controlled, although their responsibilities are well defined and subject to professional 37 w Fig . 5. Relationship between functional services and programmes for health care groups8 00 "'O Q) .., (/) Q) s:: z 3 (') 0 ii; ' Cl) C Cl) :::, Programmes for a. .., Cl) 9: !!!. :::, ~- :::, (') ,-+ (') .... m health care groups ~ :::, ~ ~ s:: .0 .... <O (') CJ 0 Q) (/) C .,, .,, ~ .,, .,, "'Tl :::, C 3 Cl) Cl) Cl) Cl) "C C "C < .., .., < < :::, a: "C < < Q) 0 "C 3 Q) c=; · :ii ,-+ (') (') (') (') :::, :::, ii; ' Cl) 0 Cl) Cl) Cl) Cl) Cl) (') Cl) <O :::, .,, .,, .,, .,, .,, Cl) .., .,, .,, ,-+ :::, Care of the elderly Child health Mental health Physically handicapped - ' ,, ' ,, ' ·~ Specialist services Support services a By courtesy of the Chief Administrative Medical Officer, Glasgow, and others. w \D Fig. 6. Proposed district management structure (administration) 8 I DISTRICT ADMINISTRATOR I Area I manager r I l Planning & development General Patient care Supplies & contracts Personnel Administrator Functional services l l Assistant Secretary I I I I I Support I I I staff Support stall Functional managers Building Sector Engineering administrator I Catering I Domestic Laundry Victoria Infirmary Fire precautions Brooksby CSSD Transport Millbrae I I Victoria Geriatric Unit Salvi car Mount Florida Secretariat - Office manager i----, r I I Service DXG I I General Service professional I I I I .Admin istrator advisory committees I I Suggestions & complaints I I I Information services I I Public relations I I Voluntary organizat ions I I I I I I I I I I I 7 I I I I I I I I District Medical Organizer of I I Records Off icer I Sector admin ist rato r 11 I Mearnskirk Clarkston Gilfnock P'hill Carnbooth voluntary services I I I I I I I I I I r Gorbals Health Centre Florence St. a By courtesy of the District Administrator . Officer Support staff District Nursing Officer ' I I ' I 1 ____ Nurse (Personnel) Rutherglen Clinic Cambuslang District Finance Officer accountability. However, advisory groups are formed to debate various ques- tions. Complaints from patients about services of general practitioners are dealt with by a special area committee. Arrangements in connexion with the administration of contracts with general practitioners are undertaken at area level, so that policy tends to be decided on that basis. Nevertheless, in this particular district no less than 46 out of I 50 practitioners are now in health centres.0 One factor that has acted as an inducement is that centres are able to provide good accommo- dation and equipment. The building and management of these centres are undertaken by the Health Board, although each centre has a committee of general practitioners. A major problem has been the lack of back-up for gen- eral practitioners by social work services, although health centres provide accommodation for social workers allocated by the local authority. Some centres have dental practitioners and almost all have excellent community health services. Other problems arising for the Executive Group and its staff are partly geographical , partly financial , partly related to staffing, and partly distribu- tional. Movements within the population have the result that the patients served do not always reside within the district boundary. A number of acute hospitals provide treatment for patients from a wide geographical area and may discharge them to "back-up" beds crossing district boundaries. How, therefore, should such services be administered? The budget for the district is about £8 000 000. Most of this is already committed, so that there is very little room for flexibility. About £100 000, however , is available for development each year. This implies constraints on planning. Problems of imbalance between various types of bed have arisen. The formation of a local health council, a new venture in bringing in the consumer, has been looked on as a helpful development by the District Executive Group. It is advisory, but has the right to approach the Health Board direct. The council is appointed by the Health Board and has repre- sentatives from local authorities, voluntary organizations, trade unions, and consumer groups. Epidemiological studies are needed both on inpatients and to sample data from general practitioners and outpatients. Furthermore , there needs to be more exchange between social work records and those of health ser- vices. 0 It is hoped that by 1985 most general practitioners in Glasgow will be working from heal th centres. 40 THE BORDER AREA HEAL TH BOARD In contrast to the Greater Glasgow Health Board, this Board is typical of a much more rural situation with a very different economic structure. The area consists largely of hilly farming and sheep-rearing country, extending from the coast on the south-east to south-central Scotland. In the south it is con- tiguous with northern England. The area of the Health Board covers exactly the same territory as that of the regional local authority; it is not divided into districts for health services purposes, although the corresponding area of the regional local authority comprises 4 local authority districts . The population is around 100 000, of whom 18 per 1000 are over 65 years old - the highest rate in Scotland. Housing in the area is not of the best quality, and local authority housing is inadequate. Private housing is difficult to come by. There is a shortage of sheltered accommodation. Another en- vironmental problem is the relatively poor communications system and the distance between centres. This has necessitated a very different pattern of service from that found in most other parts of the country. Distance makes overconcentration of staff and equipment a disadvantage to the patient. Historically, therefore, the policy in this area, still adhered to, has been to provide one major general hospital, one psychiatric hospital , and a number of smaller hospitals. In addition, the community nursing service , largely pioneered by the open-door policy of Dingleton psychiatric hospital, has provided very wide coverage. The small cottage hospitals continue to be operated by general practitioners. A laboratory specimen van collects material, delivers reports every second day, and supplies a number of emergency drugs. All doctors have access to radiological services. The principal disadvantage of the cottage hospital system is the blocking of beds by geriatric patients. On the other hand, this is to some extent out- weighed by the availability of community services and the provision of visiting consultants. The management of the Board is identical to that elsewhere. Board and Chairman are appointed, and there are a managerial executive group and five advisory committees: medical, nursing, planning, paramedical, and dental. As yet these have not settled down very well. Seven multidisciplinary planning groups have been set up to study such matters as the care of the elderly and mental health. They too are still in the process of drawing up their programmes. Board members are attached as observers. The Health Board meets at 6-week intervals. There are 15 members, but chairmen of the statutory professional advisory committees have the right to attend meetings. There is only one committee of the Board - that for works and buildings. There is considerable delegation to the Executive Group, which meets each week. The Chairman of the Board is informed regularly of its activities. Decisions within the Group on administrative matters are usually by con- sensus. Disputes can be taken to the Board. Care of the environment has been helped by the setting up of a joint environmental and communicable disease committee. This group is formed by 41 a number of environmental health officers, river board officials, veterinarians, public health laboratory workers, and community medicine specialists. All local authority directors of environmental health are associated with this committee. A full analysis of the present situation in the area has been carried out by the Usher Institute of Edinburgh University. This consists of a review of the overall socioeconomic situation and of health, social services, and transport. Further studies have been planned on the care of acute cases in cottage hos- pitals as compared with larger district hospitals. INDUSTRIAL HEALTH SERVICES The Department of Employment, which operates throughout the United Kingdom, has its own employment medical advisory service, which consists of full -time medical staff supported by the services of part-time medical staff. A new commission on health and safety is expected to reorganize the medical staff of the Department of Employment. Wider powers will be given to it to control workplaces, and it will have power to study effects outside the place of employment. Here there may well be an overlap with the environmental control now exercised by local authorities. Industrial health services cover safety, health , and welfare and do not pro- vide comprehensive medical and health care. Health care is provided in bigger establishments by the industry itself, but only to a limited degree; most care is provided by the family doctor. COMMENTS Attempts are being made to remedy the socioeconomic situation in Scot- land. Underdeveloped areas have been identified and classified, and the re- o rganization l)f local and central authorities is complete. An agency has been set up, specifically designed to promote systematic socioeconomic develop- ment - the Scottish Development Agency (SDA) - with special funding. Job opportunities have grown and will continue to grow following the investments now being made in the oil and gas fields of the North Sea. This should also din1inish the economic disadvantage resulting from the distance of Scotland from markets in Europe. The oil and gas would seem to provide a major op- portunity for Scottish economic development in the long term by encouraging the growth of new industry . No specific single national development plan has been laid down or is ap- parently expected to be laid down . However,judging from the efforts directed towards improving the socioeconomic situation, towards the regionalization of local authorities, and towards more integrated policies and programming for 42 land use and economic and social development, it is likely that a more structured form of planning will inevitably develop, if for no other reason than the logical links between these objectives. Now that the health services have been regionalized, the most detailed planning appears to have been at regional level. National or central activity is centred on the production of guidelines, emphasis being placed on particular areas of priority and allocation, coordination, and the overall direction of evaluation, training, and research. The outcome could be a situation similar to that now found in France, i.e., indicative rather than prescriptive regionalized planning based on overall agreed and nationally derived goals. The Scottish case, however, will differ in the greater emphasis given at the outset of region- alization to the planning and reorganization of the social and health services. There are, however, gaps in the planning process between the socioecon- omic and the health sectors, at central but also at operational level. At central level the use of SDA funds for industry appears to involve the Scottish Home and Health Department only marginally. Industrial health matters are not the concern of the health service but of a separate agency, part of a United King- dom Department, and to some extent of the local district authorities. The Health Department also does not appear to have a close involvement with over- all socioeconomic planning. At regional and district level there seems to be imperfect liaison with regard to aspects of policy, service provision, and coordination between the social and the health services. For example, there have-been differences about the location or removal of health facilities. The final decision on major changes in health care provision has to be taken at central level because only the Secre- tary of State has the authority to close a hospital, even though it may have outlived its usefulness. It is claimed by some planners that health centres are effective in attracting the public to use other social services located in or near them. However, general practitioners do not always wish to work from health centres and at present there are no means whereby they can be required to do so.0 The location of the centres seems to have been decided in some cases with inadequate coordination between the interested parties. On the other hand, all social workers are now local authority employees, and there are no longer any medical social workers under the administrative control of the National Health Service. Despite a large increase in their num- bers, they are still in short supply . Most health centres now operating have enough, but gen..: ral practitioners and hospitals have complained that social workers are inadequate both in numbers and in quality. It has been said that the formation of a separate single social work profession, while necessary for professional progress, has highlighted inadequacies of service, mainly because of initial understaffing in relation to responsibilities. The "new" profession, however, is attracting recruits, and considerable development of the social work services has been possible. There is certainly also a determination on the a it was noted in one area that doctors used health centres when the properties around them were substandard and eventually demolished; subsequently both the popula- tion and the doctors themselves had no option but to move. 43 part of administrators in all depart men ts and at all levels to organize joint health and socia l services in the most beneficial way for the community. A designated community medicine specialist (CMS), whose work is co- ordinated by the area CAMO, advises local authori ty districts on environmental control through the environmental health officers. The CMS has , however, no authority over the environmental health officers, nor is he able, for example, to attend a local authority environmental committee meeting except by invita- tion. Much, of course, depends on the attitudes and outlook of the CMS himself. In some instances coordination has improved. It may be asked, however , whether so much should be left to the initiative of a few individuals and whether it might not be preferable to regulate to at least a minimum extent. * * * Now that the dust raised by the extensive reorganization is settling, initia- tives and negotiations at all levels will, it is hoped , lead to suitable coordination . It is surprising that the experience of central administrators did not lead to earlier recogni tion of this problem and appropriate action. Community and personal health care have now become unified except for industrial health and local environmental control. There is now an opportunity to knit together the care of the community and that of the individual through relatively decentralized groupings. Administratively, guidance and supervisory patterns have in some cases been established within and between various pro- fessions. In o ther cases these patterns still need to be developed, particularly when skills - e.g., managerial , planning, or economic - other than those traditionally held by members of the health professions are required. An important element in the p resent and future development of the Hea lth Service has been the setting up of th e Central Planning Unit , a multidisciplinary body headed at the moment by a physician. His position carries with it duties that could well be undertaken either by a medically qualified or by an admin- istrative civil servant. The task of setting up and operating the unit has, however, been e n! rusted to a physician, but the knowledge and experience of administra- tors in health matters, e.g., in the development of national reference projections, has resulted in a knowledgeable and collaborative working group. The placing of th e Planning Unit also evince~ thoughtful and judicious innovation. It is connected directly with th e Policy Group in the central Department , and it serves as an advisory group to th e secretariat of the Health Planning Council, the main advisory body to th e Secretary of State. Two-way access exists between the unit and official groups such as the divisions within the central Department , committees, and health boards, as well as bodies representing the various professions such as the national consultative commit- tee s. This wide spread of contacts cannot but add to the value of the unit. Nevertheless, despite the view that the unit must be small, planning needs more th an liaison and advice and the preparation of briefs and projections. Fundamenta l requirements are information and tJ1e use of modern management 44 techniques and economic principles, and it is suggested that the unit still lacks them. The lnfonnation Services Division is a separate organization from the Planning Unit and is administered by the Common Services Agency. If the em- phasis in the future is to be on information for planning, it would seem that the Division could be more usefully placed alongside the Health Planning Unit, which in turn would be strengthened by personnel specially trained in mana- gerial methods, e.g., systems analysis, and in economics. The orientation would continue to be strategical rather than tactical, that is, towards such matters as the balanced development of manpower and the alternative costs and advan- tages of different priorities rather than towards minutiae and detailed pro- gramming. There has not been any great experience within the Scottish Health Service of systematic health planning, certainly not in the conceptual or anticipatory sense. Most planning in the past has been the result of external stimuli to which government has, often after the event, responded. Even where anti- cipatory planning has been attempted , for exan1ple in manpower, previous efforts were not always entirely successful. One of the main functions of the unit will therefore have to be the reorientation of the attitude of key personnel engaged in the Health Service towards a more systematic use of resources now and, more important, in the future. Whether such an activity is conducted by the unit itself or through university departments is of less importance, but the main impetus will have to come initially from the unit itself. It is apparent that by no means all those engaged in managerial and planning work are as well acquainted with organization and planning as they should be, but there appears to be a demand for training and further experience in these fields. Experience is not yet readily available either in the health sector or in the medical schools, nor are management and economic studies in universities oriented towards health. Meeting the need must therefore rest initially with the Planning Unit. Subsequently it could be in the hands of area boards, royal colleges, and universities, although the Planning Unit should continue to retain guiding functions. The work will require much persuasion, coordination, and readjustment of thinking. It is a relatively minor matter in the context of the reorganization as a whole but would seem to be important. A feature of health planning in Scotland is the endeavour to achieve as much participation as possible by the many interested bodies , professions, and communities. Centrally, the Planning Council and its secretariat have consultative committees - medical, nursing, dental, paramedical (therapeu- tic), pharmaceutical, ophthalmic, and scientific - which in turn have the power to form subcommittees. In addition there are separate advisory groups set up by and directly responsible to the Planning Council for advice on certain technical services, e.g., blood transfusion and scientific services. They may be multiprofessional and have staff from the central Department. The Planning Council has also set up several programme planning groups for services such as care of the elderly and child health. It is obvious that centrally a wide spectrum of interests has been created. The Scottish Health Service Planning Council secretariat, with 6 administrators, looks after not less than 200 meetings a year, although the Planning Council itself meets only some 3 times a year, as do the national consultative committees. These groups have been added to 45 by the liaison formed between the Planning Council, the Scottish Advisory Council on Social Work, and the Scottish Housing Advisory Committee. All these bodies are valuable in studying important fundamental issues and policies concerned with the future of the Health Service . At area and at district level, too , a number of groups have been formed, some of which duplicate the consultative and working groups at central level. They will certainly include or seek the views of local groups of hospital consultants of allied disciplines. The areas have their own health boards appointed by the Secretary of State, whose membership reflects numerous health and consumer interests. They too establish committees for special purposes, e.g., manpower, finance , and works and buildings. Finally , consumers are repre- sented by local authority and health board appointees from different local sources serving on local heal th councils ; these usually correspond to districts but more than one local health council may exist in one district. This seems, indeed, to be a structure for participatory planning that to a large extent avoids direction by small groups of administrators and tech- nical experts. Nevertheless, restrictions on the use of resources exist at all levels all the way up to the Secretary of State who , as a member of the United Kingdom Cabinet, is subject to the fiscal and other limitations imposed by government policy. * * * The reorganized and integrated health services have been functioning for little more than a year, so that it would be invidious to enlarge at length on the benefits or disadvantages of the system. It may be said that it has good historical grounds for its foundation : committees, commissions, and working groups have always been mechanisms for the management and con- trol of public services in Great Britain . It may be pointed out that the per capita expenditure on health is less in the United Kingdom than in other European and American countries . Indicators of health status stand up rea- sonably to comparative scrutiny. It may be asked, however , whether, in a period of rising prices , planning and management could not be made even more effective and efficient and services made less costly or be maintained at the same level for the same cost. Looking only at the machinery and at the numerous investigatory and interrelating points , which increase the pos- sibility of conflict, it is tempting to think that the system is , in fact, too participatory and too non-authoritarian , that there are too many checks. However, key groups and individuals are involved, such as chairmen of health boards, leaders of professional groups, and consumer organizations. Given guidance and understanding by the departmental and area personnel con- cerned with information , planning, and management, those key groups and individuals might be able to unify the system. While tactical, or programme, planning can be carried out by relatively few persons given the appropriate 46 information, for strategic or overall planning the gathering of views and in- formation initially requires the involvement of many groups. * * * One of the greatest constraints on the progress, efficiency, and effec- tiveness of the service is finance. The margin for innovation and major change is small, and there is no likelihood of improvement in the foreseeable future , even if devolution takes place and a Scottish parliament is established. One solution discussed by a number of countries is a change from hospital-based to more community-based services and the substitution of other workers for the traditional professionals. While the first part of the solution is re- garded as acceptable by most countries, the second part has met with resist- ance, particularly among the medical profession. The community service is probably better in Scotland than in many other countries, in that the gen- eral practitioner is a highly institutionalized and easily recognizable purveyor of community care, a family doctor who is strongly supported by the British Medical Association. He is also aided by other allied community profes- sionals, for example nurses, midwives, and health visitors. Now that the re- organization is settling down, there will be an opportunity for early inves- tigation of the cost-benefit, effectiveness, and efficiency of community care as opposed to hospital care and of different mixes and types of community care. With regard to resistance to the substitution of nonprofessionals for professionals, the present climate in Scotland seems in general to be forward- looking. Doctors have already largely conceded that members of other pro- fessions, in particular nurses, can perform some of their work. Some physicians find that receptionists can help as rough-and-ready screens, though whether this is ethically correct is another matter. It is, however, one sign of change in the attitude of physicians. Some countries now employ fully qualified nurses, not auxiliaries, to screen telephone calls from patients seeking advice about their complaints and about whom they should see and where. There have been few structural and well-costed studies on the effects of substitution , which may not seem to offer a very great contribution to in- novation , the ec , nomics of health services, and efficiency . However, if the exan1ple of dental auxiliaries is taken, in some countries where they are pro- duced in quite large numbers they have proved to be cheap, effective, and beneficial to the whole dental service. Some countries have approached financing from the angle of the pro- gramme budget, or more sophisticatedly, from that of a planning-programming- budgeting system. Attempts are being made to study this approach in Scot- land. While it is useful that people engaged in planning or programming should think in this way, experience suggests that it is doubtful whether any very rapid or greatly improved results can be expected to be forthcoming from such efforts alone . 47 Other measures, for example social and economic action, that could be used for the benefit of the health sector lie outside its own control. Although liaison is maintained, mainly with the providers of social services, it may be felt that the link is not yet strong enough . As far as an economic link is concerned it is possible that nothing effective really exists at present at any level. In general there seems to be a gap in the organization of health planning in Scotland that could be filled by one or more economists, provided that a suit- able career structure existed. Health economics by itself has not up till now offered many opportunities for career advancement. * * * It is apparent that much thought has been given to defining the criteria for structuring boards and districts. It is obviously impossible to satisfy all the parties and all the requirements that make up these entities. Interesting ob- servations were made by members of the Border Area Executive Group to the effect that operating in an area not subdivided into districts, where population pressures were not excessive, where there were easy con tacts and relationships with non-health personnel , and where the area offered advantages to university investigators all contributed to an impression that the situation was ideal for planning, innovation, and good organization. The case for small hospitals and community care appeared to be well made out and logical. The Glasgow area presents many more problems, most of which will be solved only in the long term. Many of the solutions , for example in the social and economic field, which will themselves affect health status, are out of the hands of the health boards. As has been noted earlier, conflicts arise between areas and districts about their respective roles and the status of personnel , hierarchical relationships, and communication between groups . It is to be hoped that solutions will gradually be found to these problems, which can cause anomalies and frustration as well as provide stimuli . The personnel in areas and districts had somewhat differing views of their functions. This again raises the question of how much more education and briefing is needed , particularly at the district level. For instance, the flow of information seemed to be better between the centre and the area than between the area and the district. Perfect solutions can obviously never be found, but changes are always being considered and attempted or rejected. A number of organizational questions were also noted at the district level. The CAMO is responsible for the coordination of the work of all the medical administrative personnel, i.e., the community medicine specialists. There is a hierarchical relationship between the secretary of the board and the administra- tors and between the CANO and the nursing staff. This relationship is con- tinued down the line in the administrative and nursing groups, but not between the district medical officer and other district community medicine specialists (although the latter may have clinical officers working for them). The question of coordination then arises. Is it possible for the CAMO, an1ong his other 48 multifarious duties, to coordinate the activities of both area and district CMSs? Why is the district medical officer a member of the district executive group if he is not placed in the same executive capacity? This matter of status and relationship can be taken further. To whom do consultants and general practi- tioners answer? What access do the district medical officer and the various CMSs have to these groups, and what is their understanding and acceptance of the role of the CMS? As mentioned in relation to the CMS responsible for environmental matters (where individual initiative is expected or implied), should there not be some mutual agreement between clinical and administra- tive groups that would make the job of the CMS easier and bear witness to the benefits others could obtain from his advice? As matters stand, the general practitioners and the consultants, for good or for ill, appear to be almost completely independent of anyone. The Jour- nal of the Royal College of General Practitioners (No. 154, May 1975) on page 314 quotes briefly from a 1971 article by R.L. Crawford & R.C. McCor- mack in the British journal of medical education, on the reasons why phys- icians leave primary practice : "It was suggested that this attribution [i.e., changing careers] might be substantially mitigated by inclusion of organ- isational, administrative, and interpersonal aspects of practice in medical training and continuing education". Here again is a plea for a greater role for communication and education in the development of staff capabilities, status, and satisfaction. Another management issue of a delicate nature concerns general practi- tioners and specialists and is connected with the quality of their work. Some evidence of quality has been implied by various ad hoc studies, and the Infor- mation Services Division has some comparative data on inpatient care. It has been suggested that all these clinicians should take more systematic stock of their own work and of that of their peers. To do this means the collection of many more data on practices and procedures. It also needs assessment, not in order to apportion blame but to improve standards. Some countries have already introduced medical audits ; others have suggested re-registration after periodic examination. In the United Kingdom foreign graduates are now re- quired to pass certain language tests before registration. Negotiations are pro- ceeding among the EEC countries on employment and reciprocity. Some further agreement now needs to be worked out by the administration on the one hand and the clinicians on the other about how to go about improving standards for the future. No account has been taken here of the consumers, for whose benefit the service is entirely designed. It has been said that consumers or patients or clients are not in a position to judge. However, an increasing number of societies, groups, and individuals are becoming more and more vocal about policies and procedures in the Health Service, and an ombudsman has been appointed. For the better satisfaction of the patient, then, clinicians may expect to be more and more pressed to face judgement on their activities. * * * 49 The assessment and training of manpower in the health professions for future needs have not yet been discussed. There is already a move towards community care and towards grouping practitioners, nurses , midwives, social workers, and others in teams. However, while industrial and commercial con- cerns carry out surveys and market research before undertaking changes in policy, changes in the Health Service seem to be based more upon assumption and less upon research. Correcting this is just as important in health manpower planning as in overall health planning. A lead has already been given by investi- gations on nursing manpower. One or two studies of manpower use and activ- ities are also being initiated in health centres, and practitioners and hospital authorities have conducted studies on manpower and service utilization. Such studies require a systematized and long-term approach and could later become a standard component of the process of matching function more closely with manpower mix and with education. This question is now exercising many countries , where operational staff, both clinical and administrative, have expressed a desire for closer coop- eration between service providers and service trainers , in order to prepare the various members of health teams better for their work in the field. Not only basic education but also postbasic and inservice training are involved. With the recent changes in the service and in alternative approaches to deal- ing with health problems, there would seem to be a need in Scotland for the reorientation of educators towards new ways of matching service re- quirements with the skills taught. There would appear also to be a need for the development of training in planning and management for all groups from basic to inservice trainees. On the basis of the knowledge acquired from this kind of training, more appropriate and collaborative attempts could perhaps be made in tackling such problems as substitution , the reclassification of beds, the reduction in the num- ber of staff supporting consultants ( combined with efforts to improve effi- ciency) and the use of health visitors in geriatric work and in child health pro- grammes. Perhaps more could also be done in these fields by service personnel at different levels , either along with or apart from academic groups. Change and development within the Health Service itself have been con- siderable and many people have shown vision. While there have been frus- trations, the upheaval seems to be beginning to result in a Health Service with a more integ1 'l ted role . The word "beginning" is used advisedly, fo r the new machinery , structures , and reorganization are not yet working easily and con- fidently. What has been achieved , however, is already noteworthy . 50 n IRELAND D.H.S. Griffith 1 & H.F.K. Ziil/ner2 Ireland is an island in the Atlantic Ocean to the west of Great Britain, from which it is separated by the Irish Sea. The administrative area to which this chapter relates covers all but the six counties in the north-east of the island, which constitute Northern Ireland. The country is governed through a President with mainly representative functions. The government is provided by the majority party or a coalition of parties, which designate the Prime Minister, who then nominates his Cabinet. They are responsible to a freely elected parliament for all the affairs of national government. At local level the counties have self-governing functions and power to raise money by local taxation, mainly on property , but most of their funds come from central grants and subsidies. The population of the Republic of Ireland numbers approximately 3 mil- lion. Dublin , the capital, and Cork, in the south, are the main cities. The pop- ulation of Dublin is over 600 000, and that of Cork 128 000. The majority of the population live in rural areas, often in widely dispersed settlements. In the past the Republic suffered from a high emigration rate. Further- more, marriage came relatively late, but families have always been fairly large to large. During the past 10 years, however, the demographic picture has changed dramatically ; there is now a net immigration and a high natural increase. This has resulted in an annual growth rate of about 1.1 %. The death rate has remained relatively steady at between 10 and 11 per 1000 population. The birth rate, w:uch had increased to 22.8 live births per 1000 in 1971, had dropped to 21 .6 per 1000 by I 97 5. 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Copenhagen, Denmark. 2 Health Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 51 The main causes of death are similar to those in other European coun- tries, i.e., cancer, cardiovascular disease, and stroke. The average marriage age has dropped but families - although quite large by European standards - now tend to be smaller. Although the country is largely Roman Catholic in religion, there is no official state religion. All denominations have freedom of worship. In con- sequence of the Catholic majority , the Church has been a leader in setting up voluntary social aid institutions. Ireland is not a rich country. Its national income per head is one-third lower than that of England and Wales. HEALTH PLANNING AT THE NATIONAL LEVEL The Prime Minister and his Cabinet are responsible for overall planning in the country. The secretariat they use, which prepares briefs for them, is the Ministry of Finance, which is certainly the prime source of information on economic planning. The same Ministry is responsible to the Cabinet for the preparation of the annual national budget, which has to be adopted each year by Parliament. Each ministerial department has planning functions within its own tech- nical domain. The Department of Local Government , for example, reviews and coordinates plans by local government (county councils) on land-use planning and zoning; this and other ministries and their departments are coordinated at Cabinet level. The final word in all cases rests with the Par- liament. The Ministry of Health has undergone massive reorganization since the passing of the Health Act of 1970. The Minister of Health at present also holds the office of Minister of Social Welfare. The Department of Social Welfare is mainly a disbursing agency for cash benefits such as unemploy- ment benefits and old-age pensions. The Department of Health also has cer- tain welfare functions. The Department of Health has been reorganized on the basis of the model recommended by the Public Services Organization Review Group (whose re- port is commonly known as the Devlin Report) . In brief, the Department (Aireacht) is concerned with supporting the Minister in the fommlation, direc- tion, and control of top level policy and overall programmes for its imple- mentation. The executive agencies are responsible for carrying out agreed policy and participating in the review of that policy, to ensure that it is geared to the needs of the day. The Department of Health, as the central policy-fonnulating body under the Minister , is responsible for: - supporting the Minister and Parliamentary Secretary in the discharge of their ministerial and parliamentary functions 52 - participating in the formulation of policy and the preparation of legis- lation for its implementation - drawing up programmes for the implementation of settled policy - coordinating, appraising , and reviewing the effectiveness of existing policies - appraising the adequacy of the overall organizational arrangements for the delivery of health services - coordinating the international activities of the service. The country is divided into eight health board areas. Each board has to organize health services and administer most of the health and health-related services within its specific area. Apart from their essential contribution to policy formulation, the major responsibility of the health boards is to trans- late into effective action, at area level , the main objectives of the health ser- vice, i.e. , to provide comprehensive patient care and to ensure that it is pro- vided as effectively and economically as possible . The Health Act, 1970, provided for the establishment of three regional hospital boards based in Cork, Dublin, and Galway. Each board is charged with the "general organization and development of hospital services in an efficient and satisfactory manner in the hospitals administered by health boards and other bodies in its functional area which are engaged in the provision of ser- vices under the I 970 Health Act". Half of the members of each board are appointed by the appropriate health boards, the Minister appointing the re- maining half following consultation with such bodies engaged in the pro- vision of hospital services as he considers appropriate. The chairmen and vice- chairmen of the boards, as in the case of Comhairle na nOspideal, are ap- pointed by the Minister. While the regional hospital boards have coordinating functions for all hospitals providing services for Health Act patients, they are not concerned with the day-to-day running of the hospitals, the management of the hospitals remaining with the health boards and the owners of the vol- untary hospitals. As a national body for hospital development, Comhairle na nOspideal was established under section 41 of the Health Act, I 970. Its main functions are to regulate the number and type of, and specify the qualifications for, consul- tant and senior registrar appointments and to advise the Minister of Health on matters relating to the organization and operation of hospital services. At present the Comhairle comprises 23 members, of whom not less than half must be hospital consultants. The Minister appoints all of the members follow- ing consultation with appropriate bodies engaged in hospital services. Not all of the executive work in relation to the health services is suited to local administration, and for those parts of it not so suited the practice has evolved of setting up special central executive agencies. Some of these were set up by special statute, others by order as corporate bodies under the Health (Corporate Bodies) Act, 196 1, which empowers the Minister to set up cor- porate bodies to administer a health service. Orders establishing such bodies , which are liable to annulment by either House of the Oireachtas (Parliament 53 and Senate), specify the constitution and function of the bodies and make provision for the appointment of staff, etc. Bodies set up under this act include the Medicosocial Research Board, the National Drugs Advisory Board, and the Hospitals Joint Services Board . The Hospital Planning Office , hitherto a division of the Department of Health, is now also an example of an executive body. This office is responsible for assisting the Aireacht in the formulation of an agreed building programme for hospitals, clinics, homes, etc., and ensuring that the programme is carried out efficiently and effectively within the resources available. In addition to the executive bodies, many of which have certain advisory functions, there are a number of central advisory bodies that contribute to various spheres of policy formulation. Foremost among these is the National Health Council, which was set up under the 194 7-1953 Health Acts and whose function is to advise the Minister on such general matters affecting or inciden- tal to the health of the people as may be referred to them by the Minister and on such other general matters (other than conditions of employment of of- ficers and servants and the amount or payment of grants or allowances) relating to the operation of the health services as they think fit. The Council is appointed by the Minister, but at least half of the members must be nominated by bodies representative of the medical and ancillary professions and of persons concerned with the management of voluntary hos- pitals. The Council presents an annual report to the Minister , who is required to publish it with any comments he wishes to make. The Minister is required also to seek the Council's advice before making any regulations. At central level the permanent head of the Health Department, i.e., the senior civil servant, is the Secretary responsible to the Minister for the opera- tion of the Department. He is assisted by four assistant secretaries , in charge of community care , hospital care and mental health services, finance, and personnel. Also in direct line to the Secretary are principal officers responsible for functions other than finance and personnel ; these are the two units for planning and organization. Under each assistant sec retary a number of principal and assistant prin- cipal officers deal with service programme and subprogramme areas such as food and drugs, psychiatric care , public health nursing, dental services , and the like (see Fig. I). They have responsibilities related to programmes and activities carried out in the field by the health boards. All these officers are administrativt civil servants without specific training in the provision of medi- cal or other health care, and their work is mainly to provide guidance in their particular field of responsibility. They may also collect or distribute data and put forward programme suggestions for consideration by the assistant secretary concerned. Advising the Secretary and his various administrative officers are a group of physicians or departmental medical staff headed by the Chief Medical Officer and his deputies. Other advisers include legal , architectural, and en- gineering staff, a nursing officer, pharmacists, a health inspector , and social workers. It is necessary for administrative civil servants to consult these medical and other advisory officers before taking major administrative steps, but in theory the administrators do not need to accept their advice . 54 Vl Vl Fig. 1. Department of Health (Aireacht) , Ireland I Personal adviser I I MINISTER l I I Private I I PARLIAMENTARY I secretary I I SECRETARY I SECRETARY I I I CHIEF MEDICAL I OFFICER I I I Planning unit Finance unit (PO•) (Asst. sec. ,• 2POs) I Community I services (Asst. sec.) I I I I I Dental , ophthalmic Food and General Welfare medical and aural services drugs services services (PO) (PO) (PO) (PO) 8 PO : Principa l officer ; Asst . sec.: Ass istant secretary. I Private secretary I I Private secretary I I I I Organization unit Personnel unit Legal (PO) (Asst. sec., 2 POs) adviser I Hospital services I (Asst. sec.) I Inspector of I Mental Hospitals I I General Mental health and services hospital services for the handicapped (2 POs) (PO) The Secretary also obtains advice from the Management Advisory Com- mittee , which consists of himself as chairman, all the assistant secretaries, the Chief Medical Officer, and such other principal officers as may be necessary depending on the subject under discussion. This committee , which cu ts across departmental divisions and staff units, has no permanent secretariat. In prac- tice , any major proposition from a particular division is first reviewed by the Management Advisory Committee. After agreement has been reached, the same division passes the detailed proposals formally to the Secretary for approval. The Secretary himself may give a decision or he may ask the Minister for one. It should be noted that the Secretary is the bridge between the politicians and the civil service . As such, he must be able to look at questions from both points of view. Answerable to the Secretary within the central Department are four im- portant units: finance, personnel, planning, and organization. The finance unit prepares annual estimates for the health services based on the estimated financial requirements of health boards and other health agencies. The funds allocated to the Department of Health through the na- tional budget, which is generally presented in January, are related to the esti- mates drawn up by the Department. In view of the present economic crisis, it is now the unpleasant job of the Department to make it clear that there cannot be growth during the current year (1976). It should also be mentioned that the possibility of additional finance by local authorities has been lost in the phasing out of local taxation for health and social care. The only compensatory mechanism that remains under local control rests in the large number of voluntary agencies. A major element in financing and accounting by the central financing section is the control of expenditure by auditing. Monitoring the expenditure of health boards and other health agencies is carried out by the finance unit on the basis of monthly returns of expenditure. Monitoring and evaluation of services on a programme basis is being conside red, and the Department of Health hopes to move towards a programme budget system with the help of the planning unit. It would then also concern itself with medium-term pro- gramme forecasts. The senior personnel officer is also an assistant secretary. He and his staff deal with recruitment policies and staff training and development as well as industrial relations, including pay levels and conditions of service for a work force of some 45 000 persons. The planning unit is small, consisting at present of a principal officer and 4 assistants ; 2 analyst posts are now being filled . The unit has been established for only 2 years. It has had difficulty in developing material guidelines for im- mediate and long-term planning. So far planning advice has been mainly on ad hoc request by other divisions and by health boards regarding short-term planning matters and statistical analyses. The 1976 financial crisis has made it difficult to interest divisions and boards in looking ahead. Also, because divi- sions tend to operate vertically through their assistant secretary, the planning unit is not yet fully involved in their deliberations. As for the health boards, many of these are only now becoming fully operational, so that the emphasis here too has been on day-to-day management. 56 The planning unit has developed provisional guidelines and standards for hospital care, which are now under discussion by the divisions and boards. It is also examining ways and means of developing national guidelines and stan- dards for community care. One particular board area might be selected for examination in greater depth and a number of meetings on this subject is in- volving divisions to a much greater extent. One other function of the health planning unit is that of supervising the Assistant Registrar-General with regard to information on certain demographic and vital statistical matters. With the reorganization of the Department, a staff unit for organization was set up. This has been mainly concerned with management strategies that would facilitate the activities of the newly established health boards. For this purpose the unit has worked closely with a consulting firm. In this area much emphasis has been placed on developmental matters, for example the pro- vision of new posts and the drawing up of specifications for changes of func- tion, new job descriptions , and the like. The question of the moment , however, is the need to use existing management resources more efficiently rather than add to them. For example, in hospital management there is still overmuch adherence to obsolete administrative procedures , whereas a more practical move towards modern management can already be seen in community care. In all, the activities of this unit are very broad , extending from such things as the provision of better staff telephones to the design of a management system for a new hospital. In sum, a health planning and management structure has existed at national level for a few years. Most health planning is still vertical, covering the separate services and therefore being dealt with by the administrative divisions con- cerned without reference to others. FINANCING OF HEALTH CARE In I 971, 4.5% of the gross national product was devoted to non-capital ex- penditure on statutory health services. This figure had risen to 6.1 % by 1976. The total operational health budget in 197 6 was estimated to be £27 5 mil- lion . This covers the budgets of health boards , voluntary hospitals , homes for the mentally handicapped, and other health agencies. Of this sum £18 million are to be obtained from extragovernmental resources, especially from health contributions (£11 million) and from rates (£5 million). A total of £27 mil- lion was approved in 1976 to be paid by the Department to a central pay- ments board, which is responsible for paying the general practitioners and pharmacists directly for contractual services to that part of the population which is eligible. In 1976 about 70% of the total operational health budget was planned to be spent on care in hospitals and homes. Community care , including cash al- lowances and welfare services, absorbs about 21%. The balance goes to central and local (headquarters) administration, finance costs, research, and certain other services. 57 Certain health services are provided free of charge to eligible popula- tion groups. Hospital care upon referral, maternal and infant care, and public health nursing are the major services that are free of charge to the eligible lower and middle income groups, which together amount to 80-90% of the total population. Persons with certain specified conditions can obtain free the drugs and medicines necessary for treatment. These conditions include mental handi- cap, mental illness, phenylketonuria, cystic fibrosis, spina bifida,hydrocephalus, haemophilia, cerebral palsy , epilepsy, diabetes insipid us , diabetes mellitus, multiple sclerosis, muscular dystrophies, parkinsonism, and acute leukaemia (children). Children who suffer from any of the first eight conditions receive hospital inpatient and outpatient services free. Typically free child health services include medical, dental, nursing, ophthalmic, and aural services - at home and at school - as well as certain social work services. Other population groups receive subsidized or free health services other than inpatient care. Entitlement to such services depends on the person's "full eligibility" or "limited eligibility". Persons have full eligibility if they are adjudged unable to afford general practitioner services for themselves and their dependants ; they and their dependants are entitled to all medical services free of charge and are issued with "medical cards". They have free choice of general practitioner and dental services and, upon referral, are entitled to specialist services, hospitalization, and certain social welfare services. In addition, the drugs, medicines, and surgical appliances prescribed are free of charge. Full eligibility is decided by the health board area's chief executive of- ficer. To maintain uniform standards of eligibility throughout the country, the chief executive officers of the eight health boards have adopted com- mon guidelines, which are reviewed periodically in the light of changes in the consumer price index. Table I is a copy of the guidelines in operation since January 1976. The distribution of card-holders (about 30-40% of the population) varies considerably according to region and occupation (Table 2 and 3). The classes of persons entitled to limited eligibility are specified in legis- lation as follows : (1) persons insured under the social welfare acts with a remuneration not exceeding £2250 per year (this limit does not apply to insured manual workers or to voluntary contributors under the social welfare acts) ;0 (2) non-insured adult persons with an annual income of less than £1600;0 (3) farmers whose property has an annual valuation of £60 or less ; (4) persons not in the above categories whom the chief executive officer of the relevant health board has judged to be unable to pay (without undue hardship) for these services ; (5) dependants under 4 years of age. a The limit of income was in creased to £ 3000 fo r bo th categories as from 1 July 1976. 58 Table 1. Standards of eligibility for medical cards: guidelines in effect in all areas as of 1 January 1976 Category Single person living alone Single person living with family Married couple In addition to the above : Allowance per child under 16 years Allowance for other dependants Allowance for expenses on house, if more than Other allowances Guidelines - Annual income (£) 1 014 884 1469 135 195 135 Reasonable expenses necessarily incurred in travel to work Persons with limited eligibility are obliged to pay a health contribution. This is not an insurance scheme, and payment of the contribution does not confer eligibility on an otherwise ineligible person. The contribution of £15 per yeara is paid in a number of ways depending on the person's category: {l) insured workers pay weekly instalments along with the social welfare insurance contribution; {2) non-insured persons pay an annual sum to the Revenue Commis- sioners; and (3) farmers pay an annual sum to the local health board. A special drugs assistance scheme applies to persons who have limited eligibility for health services and covers all insured persons irrespective of income. The scheme should be distinguished from the general medical practi- tioner scheme under which persons with full eligibility for health services, i.e., medical card-h olders, get all prescribed drugs, medicines, and surgical ap- pliances free of charge. Under the assistance scheme eligible persons recoup a proportion of the cost they incur in purchasing such items on a doctor's prescription either for themselves or for their dependants. Recoupment is made on the following basis: (a) where the total cost does not exceed £5 per calendar month, no re- imbursement; a The contribution was increased to £18 as from 1 April 1977. 59 Table 2. Number of medical cards and percentage of population in Ireland covered on 31 December 1975 No. of persons % of No. of cards (including (estimated) Health Board current on dependants) 1975 population 31.12.75 covered by medical covered by cards on 31.12.75 medical cards 603101 1 162 386 37.17 South-Eastern 72277 143178 41.02 Eastern 127 288 239223 22.44 Midland 40125 82291 44.97 Mid-Western 54592 104010 36.49 North-Eastern 54 781 109806 43.23 North-Western 55430 113692 62.13 Southern 102046 178 645 35.94 Western 96562 191 541 61.99 (b) where the total cost is between £5 and £8 per calendar month, reim- bursement of half the amount in excess of £5; (c) where the total cost exceeds £8 per calendar month, reimbursement of £1.50 plus the total cost in excess of £8. The net effect of the foregoing is that no eligible person need pay more than £6.50 in any month for prescribed drugs, medicines, and medical and surgical appliances. The remainder of the population has to make private arrangements, either by direct payment or through some form of insurance. Of particu- lar interest in this connexion is the voluntary health insurance scheme run by the Voluntary Health Insurance Board. This scheme is primarily intended to provide insurance against certain health expenses for persons not entitled to such services under the health services. However, the facility is also used by eligible persons who desire to cover themselve3 for the extra cost of pri- vate services, which are not provided under the health services. Any person under 65 years of age and normally resident in the Republic of Ireland may join the voluntary health insurance scheme (the benefits apply even during temporary absence abroad). No medical examination is necessary, but the applicant is required to give some details of his medical history and, in cer- tain cases, supply a report from his doctor. Previous illness does not pre- vent participation in the scheme, although benefit is not payable for certain ailments existing prior to registration. However, once 5 years' membership has been completed, full benefit can be claimed. 60 Table 3. Medical cards : percentage distribution of persons in Ireland covered, by source of income of card-holder (1973) Health Board Wage earners Farmers Self-employed Students Recipients of Others persons welfare allowances 32.8 12.9 1.8 4.1 45.0 3.5 South-Eastern 40.2 4.9 2.0 3.4 47.4 2.6 Eastern 32.5 1.0 1.5 6.9 52.9 5.4 Midland 47.1 10.8 2.7 2.5 32 .3 4.7 Mid -Western 33.9 7.2 2.0 3.1 51.0 2.7 North-Eastern 35.9 14.7 2.1 3.1 41.8 2.5 North-Western 33.7 21.8 0.6 1.5 38.6 4.7 Southern 28.1 10.4 2.1 4.9 50.5 4.0 Western 23.6 33.5 1.7 3.5 36.4 1.3 °' Insurance begins after 13 weeks except in the case of accidents, when the insurance is valid from the day it is taken out. Conditions arising prior to the expiry of the 13-week period are not covered. Normal maternity care and routine dental care are not covered by the scheme. A hospital scheme leaves it to the person insured to decide how many "maintenance units" and "treat- ment units" he wishes to buy. They entitle the holder to specific cash benefits, while a supplementary home scheme insures against major medical expenses (for further details see Annex 1). Nearly 525 000 persons were members of the scheme in February 1975. PLANNING OF COMMUNITY HEALTH CARE The general medical services have the major part of community care. This covers the services of approximately 1300 general practitioners,0 the maternal and infant care scheme, child health, the care of preschool and school children, public health nursing, chiropody, the development of health centres, the de- velopment of community care teams, dental programmes, and ophthalmic and aural services. Several other sectors have some responsibilities in the field. One deals with mental handicap, psychiatric services including alcoholism, drug addiction, and vocational rehabilitation of all the handicapped. Another deals with food, drugs, and public health. Food hygiene is covered and also prevention of the sale of diseased or contaminated food or food otherwise unfit for human consumption. The control of drugs covers the quality, safety, and efficacy of drugs and medicines manufactured and marketed in the country and also control of drug abuse. Public health measures include the prevention, control, and notification of infectious diseases, national guidelines for immunization programmes, a special tuberculosis scheme, the control of tobacco promotion, and medical uses of radiation . In Ireland group practice by general practitioners is very rare. Most prac- titioners work single-handed, but make their own arrangements for holi- days, weekends, and the like. They are free agents, contracting privately with health boards for the care of the eligible population. For services to holders of medical cards the general practitioner is paid either for patients' visits to his consulting-room or for his visits to their homes. The payment system is called "payment by item of service". Contracting physicians and pharmacists are paid by the General Medical Services (Payments) Board (see Annex 2). The number of card-holders per physician is not normally allowed to exceed 2000. a The total number of general practitioners (GPs) is 1500, of whom 1300 participate in the choice-of-<loctor scheme; a further I 00 participate in the maternal and infant care scheme. 62 Antenatal and postnatal care is provided free of charge for the fully eligible and limited eligibility groups (together about 80-90% of the total population). About 99% of all deliveries in 1974 took place in hospitals or maternity homes , compared with about 80% in 1961. However, women may elect to attend a general practitioner and a midwife (mostly a public health nurse) for antenatal and postnatal care, the latter lasting up to 6 weeks after delivery. They also have the choice of attending a hospital for the same ser- vices. The overall policy on delivery is one of a short stay in hospital. In general the policy for maternal and postnatal care is to make use of the general practi- tioner. An adequate back-up specialist service is available, based on specialist maternity hospitals and specialist maternity units in general hospitals, where women can be referred by their medical practitioner for specialist care, in- cluding inpatient hospital care, if considered necessary. Of all newborn infants in 1974, 99% were screened for phenylketonuria ; the incidence per 100 000 tested was found to be 19 .1 . Preschool child health service During the preschool period, i.e., from 6 weeks to 4 or 5 years of age (af- ter which children attend school in this country), children come under the care of the preschool child health service. This service was introduced in its present form in 1970 on an experimental basis in selected areas. It was intended to ex- tend it to the whole country when its value in the early detection of disease or defect in children was proven and it had been perfected on the basis of experi- ence gained. The child health service for preschool children is organized on a local basis in each health board area. Under the board's auspices a free paediatric examination service is provided for eligible children, i.e. , children living in cities and towns with a population of 5000 and over. The service includes paediatric examinations of development at the age of 6 months, 12 months, and 2 years (approximately) . The examinations are carried out by assistant chief medical officers who have received training in performing such examina- tions. A very high percentage of eligible children undergo a full paediatric examination at approximately 6 months, and a smaller but quite significant percentage of children receive the full examination when they are I year and 2 years of age. As the aim of the service is to detect at the earliest possible age any disease or defect in children, those involved in the service tend to place emphasis on the widest possible coverage of children at the age of 6 months rather than on more concentrated and ongoing assessment of a small group of children. The child health service for preschool children is regularly reviewed with a view to improving its effectiveness. However , up to the present it has not been possible to extend the service beyond the urban areas to all areas of the country because , firstly, it has not yet been fully evaluated and , secondly, present economic considerations and the Jack of sufficient staff preclude its extension. Interim arrangements are, however, in force in areas to which the service has not yet been extended . Public health nurses specially trained in child care carry out regular home visits to families with young children, as part 63 of their preventive nursing duties. Children are seen at least three times before the end of their first year and also during the second and third years of their life. If a child gives the visiting public health nurse cause for concern, the nurse may refer it for medical examination. The public health nurse is a modern type of multipurpose health worker. She is trained for 3 years in basic nursing. This is followed by I year of training in mid- wifery and subsequently by yet another year in public health, with particular em- phasis on prevention and the promotion of health care. The scheme was modern- ized 6 years ago, has proved to be very successful, and is widely accepted by the community. At present there are 890 public health nurses in the country, and the ratio of public health nurses to the population is I : 3500. The actual ratio is better in terms of the actual number of persons served, since certain services, e.g., curative care, are not normally provided to the well-off. The target at present is to improve the ratio, particularly in the rural areas. Some of the principal assets of the public health nurse are : ready access by the whole community; provision of both preventive and curative care; continuity of care; better attention for children, mothers, and old people; and close liaison with general practitioners and consultants. On the other hand, she has at present insufficient links with hospitals. Efforts are now being made to promote links through superintending public health nurses and matrons of hospitals. The em- phasis is to be on the exchange of information and the follow-up of patients. The public health nurse is also the main con tact for bringing in mothers and children for the vaccination schedule. The nurse herself gives the oral poliomyelitis dose; other immunizations are carried out either by assistant medical officers of the health board or general practitioners ( except in the case of BCG, which the newborn can receive in hospital). All immunizations and vaccinations are voluntary and free of charge to all children. School health service The school health service in its present form was introduced in 1970 at the same time as the preschool service. Like the preschool service, it was first introduced in a limited number of schools throughout the country, i.e., all national primary schools, which cater for the vast majority of primary pupils. It is intended to extend the school health service to other primary and post- primary schools when it has been shown to be effective in the detection of disease or defect in schoolchildren and when the necessary financial and staffing resources are available to provide for a more extensive service. Under the school health service all eligible children, i.e., all children at- tending national primary schools, undergo one comprehensive medical exam- ination towards the end of their first year at school. In addition, further selec- tive medical examinations are provided for children whose medical condition gives cause for concern to their parents , teachers, nurses, or any other in- terested parties during their time in primary school. Dental services Public dental services are provided for specific groups by publicly em- ployed (health board) dental officers, and in some areas by private dentists 64 who provide services on a part-time basis in their own surgeries or at health centres. The priority groups are mainly preschool and national school children referred by the child health service. Others are persons with full eligibility for health services, mainly holders of medical cards and their dependants. Because of the shortage of public dentists, most adults are required to go on a waiting list, except in emergency cases. The situation is gradually improving; there are now 184 filled posts, but there is a shortage of dental specialists such as ortho- dontists. In some rural areas dentists use mobile trailer units. It is hoped in the future to cover secondary and vocational schoolchildren as well. At present the law does not permit the use of dental auxiliaries other than dental receptionists, who do not provide patient care. In the bill to amend the Dentist Act, 1928, it is proposed to make provision for the recognition of this type of dental personnel. In Ireland more than half the population is served by water supplies equipped for fluoridation. Fluoridation is carried out on an agency basis for the respective health boards by the local authorities responsible for monitoring the water supplies concerned. So far, research results indicate a possible 70% reduction in the incidence of caries in deciduous teeth and up to 50% in the permanent teeth of young children. The number of dentists, mainly private practitioners, registered with the Dental Board is steadily increasing. Private dentists also contract with the De- partment of Social Welfare to provide services for qualified insured persons (but not for their dependants). The total number of insured persons covered by this dental benefit scheme is around 800 000. Later the responsibility for this scheme may be shifted to the Department of Health. Other services National school pupils and preschool children found to require ophthalmic services (including sight tests) are referred by the child health staff to visiting ophthalmic consultants at health board or hospital clinics. Eligible adults, i.e., holders of medical cards and dependants, may be referred to such clinics by their general practitioner, but in most areas there are waiting lists. Insured workers are eligible for eye examinations and spectacles, if necessary, under the optical benefit scheme of the Social Welfare Department, which has contracted with opticians and ophthalmologists to provide services under the scheme. Services for hearing defects are provided for children and adults on lines similar to the ophthalmic services. Patients requiring hearing aids are referred to the National Rehabilitation Board, which operates a hearing-aid service on behalf of all the health boards. Finally, about 150-200 chiropodists are employed by health boards on a sessional basis, particularly for the care of the feet of the elderly. On average, each elderly person receives about 4 visits per year. Infectious diseases A number of common diseases and scheduled conditions are notifiable. The responsible central division collates the notifications, forwarding them to the Central Statistical Office, and distributes the resulting information. The 65 usual difficulties are experienced in getting a satisfactory proportion of cases other than serious ones notified. The reward for notification has fallen in value because of inflation. On the other hand, respiratory tuberculosis is handled well. Its incidence declined satisfactorily over a period of about 20 years, though the decline has recently slowed down and the incidence is still fairly high. It is being dealt with almost entirely by public physicians and officials. The schedule of notifiable diseases is at present under review. A problem may arise with regard to bovine tuberculosis. The country has been free for years and all animals have either been slaughtered or protected by BCG. At the moment, however, veterinarians are showing some reluctance in carrying out follow-up tuberculin testing. A miniature X-ray service is no longer promoted by a central authority, though the service is available for risk groups at the request of health boards. Vaccinations for certain diseases are carried out on a routine basis free of charge, but are not compulsory. The responsible central division prepares na- tional guidelines for vaccination programmes and collects information about their progress. At present vaccination is offered for diphtheria, pertussis (now sometimes omitted), tetanus, poliomyelitis, and rubella. BCG is treated separ- ately. The acceptance rate is reasonably satisfactory - usually higher than 66-70% of children. Booster doses, where appropriate, are given. The responsibilities of this division in connexion with drugs and medi- cines include : licensing of the manufacture and marketing of medicinal prod- ucts ; control of the sale of medicines to the public ; the testing of medicines for quality, safety and efficacy; and prevention of the misuse of drugs. It also supervises the application of the food hygiene regulations to manufacturers and the sale of food to the public. The Food Advisory Committee , a multidisciplinary body, advises this division on the microbiological and nutritive aspects of food and also on the control of additives and contaminants in food . The Joint Services Committee on Zoonoses, a body composed of doctors and veterinarians, gives advice on prevention and control of zoonotic diseases. The division is also responsible for the control of tobacco promotion and medical radiation, the licensing of experimentation upon live animals, and the control of poisons. SOCIAL SERVICES Personal social services are being developed under the aegis of the Depart- ment and administered at local level by , or with the support of, the health boards. While health boards have a responsibility under the Childrens Act , 1908, for the care of children, it is not their responsibility alone; arrangements for the care and control of children who are committed by the courts rests with the Departments of Justice and of Education. There are, however, very close working arrangements now between the three departments. A task force on child care services is reviewing the entire field of child care and has been asked to prepare a draft bill updating and amending the legislation relating 66 to children. Under a government decision taken in 1974, the Department of Health has coordinating responsibility in relation to child care. The total number of children in care is about 2600, of whom about half are in residential care. The residential homes mainly come under the aegis of the Minister of Education, although there are a small number of homes recognized by the Minister of Health as being appropriate for the care of children. The homes cater for children placed in care by the health boards and children committed by the courts. A senior social worker, with a supporting team of fully qualified social workers, is attached to each community care team. The social workers are dis- tributed throughout the area and generally work in close cooperation with the other disciplines both at community and at district level. Most social workers have general responsibility, but there are specialist psychiatric social workers at- tached to the mental hospitals who provide a service for those in an acute stage of illness. The tendency, however, is to develop an integrated social work service, suitable opportunities being given for social workers to develop special interests and expertise. At present social workers employed by health boards concentrate on child care, difficult family situations, and the development of voluntary social service effort. The health boards also support a number of organizations who employ social workers, although there is a tendency to discourage the employment of social workers who would be engaged in narrow specialist activities. "Meals-on-wheels" are provided for about 2% of the population aged 65 years and over, and home help services are provided for about 1.3%. The Department and the health boards give high priority to the development of improved services for the aged, so as to maintain them longer in the community and give them the maximum support in their own homes. When people are no longer able to be maintained at home but do not require continuous nursing care other than that provided by public health nurses, accommodation is provided in welfare homes. At present there are 24 such homes throughout the country, generally staffed by a matron or supervisor and a small number of nurses assisted by domestics and a cook. Methods of providing such care are under regular review and there is a likelihood that the size of the units will be reduced, so permitting a greater measure of decentralization, the people being kept as close as possible to their own communities. Considerable emphasis is placed by the Department and the health boards on the maintena, ce and development of the voluntary sector , which not only contributes handsomely to the provision of services but is instrumental in de- veloping new services and involving a greater range of people in worthwhile community-based activities. Arrangements are gradually being developed for better cooperation at local and health board level between the statutory and the voluntary sectors. The voluntary sector has a significant representation on the National Social Service Council, which is a body devoted to the develop- ment of the voluntary sector, the provision of a wide range of information on social services, and the improvement of cooperation between the voluntary and the statutory sectors. The Director of Community Care and the senior social worker play a vital role in coordinating the arrangements for dealing with cases of non-accidental 67 mJury to children. The Department is about to issue detailed guidelines to health boards in order to reinforce the existing arrangements. In addition,health boards are becoming involved in the support of voluntary organizations dealing with groups such as battered wives , single parents, and others with special difficulties. There is a great variety of voluntary effort , which has grown sig- nificantly in recent years , and practically all the voluntary agencies look to the Department and the health boards for financial support of some kind. The social services administered by health boards include a range of cash benefits payable to those disabled by infectious diseases, by blindness, and by other handicapping conditions. In addition , arrangements are now being made to have the new supplementary welfare allowances scheme ad- ministered by health boards as part of the rationalization and development of the social services. PLANNING FOR HOSPITAL CARE The general hospital system is at present undergoing considerable re- organization. In June 1968 the Consultative Council of the General Hospital Services reported to the Minister of Health on future policy on the develop- ment of acute hospital services throughout the country. The Council {whose membership was made up of consultants in hospitals in several parts of the country) recommended that the then existing system throughout the country, whereby specialist services were provided in many hospitals usually staffed by single surgeons and single physicians, should not be continued. They thought that the concentration of specialist facilities in fewer , better staffed hospitals, offering better facilities was needed to provide adequate services in the future . The Council proposed the concentration of facilities for acute hospital care in 16 centres. While the Council's report was accepted in principle by the then Govern- ment, and while from the medical point of view the recommendations were logical, it became clear in subsequent years that the detailed concept as set out did not pay sufficient attention to the practical needs and wishes of the people. The Minister of Health in 1973 initiated a process of widespread consultation involving the health professions, the local bodies, and a new body concerned especially with the development of hospital services (Comhairle na nOspideal), which had been set up in the mean time to seek a consensus on the future development of the hospital system. The consultation process was started by asking Comhairle na nOspideal to produce guidelines for the development of the future hospital system. These guidelines , which were completed in September 1973, modified the earlier recommendations and proposed that : (1) the general aim should be to organize acute hospital services so that the population served would be within a radius of 30 miles of the hos- pital centre ; 68 (2) the minimum staff of such a hospital should consist of 2 consultant surgeons and 2 consultant physicians, with other consultant medical personnel and other staff as required by the caseload; and (3) a minimum-scale consultant-staffed hospital conforming to the guide- lines should usually serve a population of about 100 000, but where there were special considerations such as low population density a lower figure would be appropriate, ranging down to 75 000 in exceptional circumstances. In its introduction to its guidelines, Comhairle na nOspideal stated: Developments in the practice of medicine in hospitals ... have laid in- creasing emphasis on the contribution of laboratory, radiological, and other scientific investigation to patient care, and in addition have called for the involvement of a number of clinical consultants in dealing with difficult problems of complex disease and injury. The general move in the direction of a shorter working week has also been felt in the hospital services ... All of these developments, coupled with the beneficial tendency towards a greater degree of specialization by consultants, have pointed towards the need for the organ- ization of general hospital services on a broader medical and technological base within the hospital and an enlarged population catchment related to the increased capability of the larger hospital. In short, the idea of a single-handed surgeon or physician attempting to provide a 24-hour service with the assist- ance of supporting medical staff and less than adequate laboratory and radio- logical services is no longer acceptable from the point of view of the patient's best interests . . . Large hospital centres would be highly desirable in situations where the population would justify this. However, the Comhairle, recognizing the twin difficulties of mountainous terrain and sparse population in parts of the coun- try, acknowledges the appropriateness of smaller hospitals to cater for such situations. They would emphasize that such smaller hospitals should be within a reasonable distance of a larger hospital centre where some of the more specialized facilities would be available .. . This should permit patient care problems of special difficulty to be handled on a joint resource basis and should encourage a spirit of mutual assistance on a wide range of activities. The Minister accepted the Comhairle guidelines as a reasonable basis for improving the hospital service and for decisions on the future system. The next step was to move towards decisions on the centres for development in accor- ance with the guidelines. It was considered important to involve in this all the new health administrative bodies set up under the Health Act of 1970 - the health boards with their local advisory committees, Comhairle na nOspideal, and the regional hospital boards. For each health board area a working group drawn from the health board, the Comhairle, and the regional hospital board surveyed the available facilities and, in the context of the guidelines, con- sidered what realistic options existed for future policy. Each of the bodies involved expressed a choice between these options and each county health advisory committee within the health board area had the opportunity to state its opinion. All these views were presented to the Minister. Each body ex- pressed its own particular point of view and, because the interests of the dif- ferent bodies diverged, there were naturally different opinions. It is significant , 69 however, that in general they accepted the concept of the guidelines ; the question in any case was about a choice between centres of development rather than about the concept of development in all centres. In October 1975 a general hospital development plan was announced by the Government following its consultations. Under the plan a full range of facilities will be available in 33 hospitals at 23 centres throughout the country. These will ensure that everyone, except in unusual circumstances, will be within approximately 30 miles (50 km) of a general hospital. Highly specialized treatment will be provided in a limited number of centres (at Cork, Dublin , and Galway) for the whole country. Table 4 gives selected statistics for acute hospitals. Psychiatric care The majority of psychiatric beds are under the control of the health boards. In all there are 22 health board psychiatric hospitals, many of which are more than 100 years old, each serving one or more counties ( there are 3 such hospitals in Dublin). At present there are 13 800 beds, of which 3000 are occupied by mentally handicapped patients. This is a reduction from 18 800 over the past 12 years. In addition there are 12 private mental hospitals providing a total of 1190 places. In future it is hoped to send all short-stay acute cases to special 40-50 bed units in general hospitals, but this will take some time to achieve. The reduction in beds has been achieved by the use of modern therapy, which greatly reduces the need for long-term stay. Nevertheless, about 20% of the inpatient population have been institutionalized for 25 years or more. A study of causes for first admissions from 1965 to 1972 showed that there has been a great increase in cases of alcoholism but, largely owing to more effective outpatient attention, fewer cases of neurosis. There is little variation in the incidence of schizophrenia, which represents about 20% of all first admissions. Statistics of attendances at the National Drugs Advisory and Treatment Centre and of prosecutions for trafficking in and possession of drugs illicitly appear to indicate that drug abuse is not a major problem in Ireland. Because of the early discharge policy, outpatient psychiatric services are largely provided through clinics associated mainly with psychiatric hospitals and at present through a few general hospitals and community health centres that a psychiatrist visits at regular intervals. Psychiatri r, nurses based at local mental hospitals provide a domiciliary service in the p ... tient's own home. This domiciliary coverage is not yet adequate. The reasons for this are complex, one of them being that psychiatric nurses can obtain better salaries when working in hospitals. Additional efforts are being made to increase the number of follow-up hos- tels and group homes in preparation for full return to the community. Hostels have a permanent psychiatric nursing staff - l nurse per 5-10 patients. Group homes are supervised by nonresidential nursing staff. Efforts are also made to find both open and sheltered employment. Up to 1965, when a Commission of Inquiry on Mental Handicap reported, there were 19 residential centres catering for a total of 3414 mentally handi- capped of all categories (Table 5). In addition there were approximately 70 Table 4. Acute hospitals: selected statistics 1974 and 1975 Average cost Number of Number of Patients treated Average duration of stay per patient in Type of hospital hospitals beds in days December 1976 1975 1975 (estimated) 1974 1975 1974 1975 £ Health Board hospitals Regional 8 2085 70452 73947 9.6 9.5 263 County 24 3250 109879 113 332 9.1 8.8 187 Distr ict 51 1967 27043 27622 20.0 20.8 218 Fever 8 591 8330 8885 17.9 17.2 182 Orthopaed ic 5 655 7980 8753 25.4 23.0 309 Total 96 8548 223684 232 539 11.5 11 .3 Voluntary public hospitals General (teaching) 16 4224 98535 102849 13.7 13.2 348 General (non-teaching) 7 975 32664 32307 9.4 9.7 219 Maternity 5 933 43329 43 780 7.0 6.7 176 Paediatric 4 746 21821 24 413 10.8 9.5 250 Cancer 3 307 5533 5 723 15.9 15.2 378 Eye and ear 2 230 8494 8149 8.1 7.8 179 Orthopaedic 5 706 5093 4 729 36.2 37.5 309 Cottage 5 141 1858 1 524 22.7 29.6 252 Total 47 8262 217 327 223474 11 .1 11.5 Private hospitals 16 1442 Not available 40240 Not available Not available Not available Total 159 18252 441 011 496 253 11.3 11.4 - - --.J - Table 5. Services for the mentally handicapped in Ireland: numbers catered for in residential centres and day centres at 31 December 1974 Residential centres Day centres 0-16 years 16 years 0 - 16 years 16 years and over and over Mildly handicapped 844 295 2633 266 Moderately handicapped 848 1262 1 102 461 Severely handicapped 710 734 278 100 Total 2402 2291 4013 827 Source: Returns to the Department of Health . 3000 adult mentally handicapped in the district mental hospitals. There are now 44 residential centres providing 4693 places. The number of places for children is now deemed to be nearly adequate, if the blocking of children's places by adolescents and young adults could be relieved. The provision of adult accommodation is now the major problem, but the cost of residential care has now escalated to such a degree that the recurring financial implica- tions of the provision of additional places has to be examined very carefully . Ideally , village-type developments would be the most favoured and a number have been provided , but the cost implications are proving formidable . Day care, education, and occupational training are now provided for 4840 patients in 81 day centres. In future every effort will be made to avoid residential and institutional care, although it will often be inevitable . The emphasis will therefore be on day care. In 1975 a working party proposed a number of guiding principles for im- proving rehabilitation procedures for both the mentally and the physically handicapped. A register should be established of all the handicapped in each health board area. All the handicapped should be assessed in relation to their potential suitability for either sheltered or open employment. Where skills can be developed the Government's Industrial Training Authority should take responsibility. Where special skills cannot be developed training in unskilled work should be provided through community workshops; they are usually or- ganized by voluntary agencies and financed through government grants . The working party proposed that , within the broad policies adopted by the Minister of Health , the National Rehabilitation Board should be the main executive agency for rehabilitation policy. The Board is funded through the Department of Health, and it also undertakes such work as the provision of hearing aids and the training of occupational and speech therapists. 72 In spite of the overall emphasis on community rather than on hospital care, the hospital sector still employs about 73% of the total health manpower, while community care accounts for only 15% - the remaining 12% providing the support services. THE SOUTH-EASTERN HEALTH BOARD The country is divided into 8 health board areas, one of which is the South-Eastern Health Board area. Like the others, this one has a board of management which represents local interests. Its members come partly from among the elected councillors of the 5 counties in the Board area, whose mem- bers comprise parliamentarians, members of trade unions, and representatives of voluntary agencies. The majority of the members are appointed by the con- stituent local authorities. The Board has its headquarters in the city of Kil- kenny, a town located almost in the centre of the area . The largest city is the port of Waterford in the south, with a population of 32 000. With the formation of the boards there has been a major transfer of powers from the county councils. The health board has the responsibility for determining needs and resources and for monitoring its own programme and budget. It reserves to itself the approval of plans, the budget, and certain major capital work . The secretariat or management team for the board consists of full-time public servants : the chief executive officer, the programme managers , the finance officer, personnel officers , technical services officers and, in some cases, the planning and evaluation officer. In the South-Eastern Health Board planning and evaluation are handled by a staff member of the Finance Office. The management team is usually nonrnedical. In the South-Eastern Health Board one programme manager is a physician. The Chief Executive Officer (CEO) is responsible to the board for the complete management of health and social care as already described . He has the statutory function of deciding who is eligible to hold a medical card . The provisions in the Act on his functions marked a departure from the County Management Acts, which governed the management of the health services under the former local administration . These Acts gave to the county man- ager the statutory responsibility for most of the functions of the county council. Under the Health Act, 1970, however , only a limited number of decisions, mainly relating to personnel matters and the eligibility of indi- viduals for services, are made by the CEO on his own authority. In all other matters , the CEO himself and the other officers of the board are specific- ally required to "act in accordance with such decisions and directions {whether of a general or a particular nature) as are conveyed to or through the CEO by the board and in accordance with any such decisions and directions so conveyed by a committee to which functions have been delegated by the board". 73 In practice, however, the health boards have recognized the need to dele- gate day-to-day management on a considerable scale to their CEOs and other officials, while retaining ultimate control in their own hands. The following are the main matters on which boards generally decide themselves : - the approval of estimates or of changes in estimates - the authorization of capital schemes or the borrowing of money - the acquisition and disposal of land or premises - decisions on programmes for the development of services and the re- view of such programmes - decisions under a special section of the Health Act , 1970, relating to the provision or discontinuance of premises. In practice , the CEO is expected, along with his management team, to lay down guidelines for the detailed planning, programming, management , and evaluation of health board activities. There are three programme managers in the South-Eastern Health Board area. One is responsible for general hospitals , one for special hospitals ( e.g., geriatric and for the mentally ill and mentally handicapped), and one for com- munity care. The Health Act , 1970 , provided for the establishment of local committees whose function is to advise the health board on the provision of health services in their area. Most counties have one local health committee (the densely populated counties have more) and, as in the case of the health boards , the majority of members are local councillors. The balance of membership is generally made up of the county manager ( or his nominee) , the county medical officer ( or his equivalent), the medical superintendent of the district mental hospital (or a senior psychiatrist), a consultant from a general hospital , two other doctors elected by the profession, the superintendent assistance officer (or his equivalent), a psychiatric nurse, a public health nurse, a dentist, a phar- macist, and two other persons, not being councillors, who are associated with voluntary organizations in the sphere of social services. Meetings of the local committees are attended by senior officers of the boards. The gross operational budget for the South-Eastern Health Board for 197 6 was £23 millie,n. It does not cover payments for general practitioners and the financing for large voluntary hospitals, which are made from the centre. Of the total operational budget , £14.05 million was for staff pay . At the time of the visit no increase in the budget was foreseen. There was, therefore, a good deal of discussion on present priorities in all areas , especially as regards the strengthening of community care and potentially necessary cuts in inventories and stocks. Fortunately , the economic situation of the health and social welfare sector has improved considerably since, owing partly to general economic improvement and partly to the usefulness of the sector in the creation of additional employment. A list of hospitals and key health manpower in the area is given in Table 6. 74 Table 6. Selected health resources in the South-Eastern Health Board area A. Distribution of hospital beds Hospital Total Surgical Medical Maternity Children Other beds Kilkenny County Hospital 174 71 50 28 25 Tipperary (South Riding) County Medical Hospital, Clonmel 114 66 27 21 County Surgical Hospital, Cashel 92 65 10 6 11 Waterford Ardkeen Hospital 204 59 54 14 77 County and City Infirmary 78 27 28 9 14 Airmount Maternity Hospital 54 50 4 Wexford Wexford County Surgical Hospital 111 69 22 20 Wexford County Medical Hospital, Enniscorthy 80 66 14 Total 907 291 274 147 100 95 The total population in the area in 1971 was 328 604. B. Number of psychiatric patients on 31 December 1974 The number of psychiatric patients in the area on 31 December 1974 was 2261 . C. Distribution of medical manpower Doctors ( 1975)a Public General Dentist~ health All Consul - Junior practi - Public nurses nurse~ tants doctors tioners health (1975) South-Eastern Health Board area 48 51 161 15 63 102 1946 Whole of Ireland 853 1 259 1 500C 132 659 797c 19284 a Some doctors are not included here, e.g., those employed by the Department of Health (14) in full-time research, those serving in the army, and those in private practice only. b This information is taken from the Census of Population, 1971 . c Estimated/approximate . 75 PLANNING REGIONAL COMMUNITY CARE This programme encompasses all the community health and social pro- grammes provided by the Board. It is directed by the community care programme manager, in this case a physician. For the purpose of this programme the Board area, with a population of about 330 000 , has been divided into 4 community care areas, with roughly equal populations of 78 000-85 000. The tendency is to make these areas co-extensive with the county area, but in one case the county is so small as to require its combination with another. In other parts, for the convenience of communities , some adjustments have been made crossing county boundaries. In each council area0 there is a local health committee to advise on health service needs. Voluntary agencies are represented on each committee. It should be noted that county councils have retained the responsibility for certain statutory activities , mainly in the field of environmental control, in particular housing, pollution , land-use planning, sanitation, and water supply. In the South-Eastern Health Board several health inspectors have been seconded to work full-time on county council work. In each of the four community care areas there is a director of community care and medical officer of health. He is always a physician, selected after pub- lic advertisement of the post by a national statutory commission. He leads a community care management group, which consists of an administrator, whose role is primarily supportive, assistant medical officers, a senior dental officer, a superintending public health nurse, a senior social worker, a senior health inspector, and a senior assistance officer. Because the Board has only recently been established , and for other rea- sons, a number of the staff from Board level down are acting in their positions ; for example , not every director of community care has yet been appointed, the positions at present being generally filled by former county medical officers. The director of community care will be fulfilling a broad managerial role in both health and social care and will also have responsibility for preventive and en- vironmental health in his area . For the moment much of the managerial function may in practice rest with the administrators, who have always eased the task of the senior medical staff in public health. It is they who are concerned with budgets, staffing plans, and other managerial functions . They have also some delegated functions in handling and reviewing medical card-holders. Some assistant medical officers will be appointed with the duty of depu- tizing for the director of community care and may also be responsible for im- plementing a community care programme for a defined district. They may also assist the director in relation to a particular aspect of a community care pro- gramme in which they have a special expertise. 0 At present these are Carlow, Kilkenny , Tipperary (South Riding) , Wexford , and Waterford . For health board purposes Carlow and Kilkenny may be regarded as one com- bined area . 76 The senior dental officer plays a similar role in that he is part of manage- ment , leading a team of dental officers as well as carrying out his own dental work. The superintending public health nurse reports directly to the director of community care. She organizes the public health nursing staff of the area and may also, if required, undertake the duties of a public health nurse. The senior social worker, in her present office, is a relatively new member of the community care management team. As such, she is responsible to the director for organizing and supervising different social programmes. Her work includes liaison with the local social service council. Voluntary agencies - both clerical and lay - make a significant contribution to the provision of some ser- vices corning within the health board's responsibility, e.g., "meals-on-wheels". Social workers employed by the board and voluntary agencies who are finan- cially subsidized by the board come under the supervision of the senior social worker. The senior health inspector also has a team of health inspectors and, like other senior officers, has management and supervisory functions . The senior assistance officer is a relic of the former county council control of supplementary welfare allowances - earlier called home ( or public) assistance. He and his staff assess needs and provide help in cash and kind to the least af- fluent in the community. They also carry out investigations of eligibility for medical cards. In the South-Eastern Health Board two county councils opted to retain the assistance officers they employed. Other county councils agreed to transfer staff and functions to the Board. It is anticipated that before long all assistance staff will come under the Board. During the past year efforts have been made to stabilize the management at community care area level. Much information is now exchanged by each management team at monthly meetings. These meetings have developed a much more managerial emphasis in that senior officers are better able to see the effects or consequences of their own programmes upon other staff. The South-Eastern Health Board area was formerly divided into about 90 dispensary districts. In each district the service was provided to the eligible population by the district medical officer, a permanent part-time pensionable officer of the then health authority. The district medical officer was entitled to engage in private practice. With the reorganization several changes occurred. The post of dispensary doctor was abolished. General practitioners now parti- cipate on the basis of individual contracts. The eligible card-holder is allowed free choice of doctor. The former dispensary doctor, along with all other general practitioners wishing to join the medical card scheme, was required to apply to the health board. Former dispensary doctors were allowed to continue to use their former premises. As already mentioned, a general medical practitioner's list of eligible persons, including dependants, is limited to 2000 individuals. At present a new general practitioner can be admitted to the scheme only when a vacancy occurs or when a post is created by the health board, the vacancy being advertised and applicants interviewed. During known absences doctors have normally to arrange for the care of their own patients. Unavoidable absences are taken care of by the board. 77 To encourage group practice, a doctor anticipating a large list has the right to ask for an assistant, who may later become a partner. Payment to general practitioners is basically through the National Payments Board in Dublin. Boards and directors of community care receive summaries of visits to doctors by card-holders. These monthly summaries compare each doc- tor's visiting rate and prescription costs with national and health board averages. It is the duty of the director of community care to draw attention to rates or costs that are excessive. Action can only be taken at national level. In the whole South-Eastern Health Board area there are about 150 general practitioners , of whom about 130 participate in the scheme. A feature of the Board is a quarterly meeting on a community care area basis between general practitioners and the community care management team (or part of them). This has led to mutual exchange of information and is used as one means of guidance by the Board. In addition the public health nurse will assist the general practitioner on request , largely in curative care and follow up. This is over and above joint prenatal and postnatal work. The director of community care also makes nursing and equipment available for domiciliary use when the practitioner is maintaining treatment on that basis. In a rural district there are usually one doctor and at least one public health nurse who form the nucleus of a primary care team. They have access to social workers, social assistance officers, and other community care providers. Most other community care work is done at public clinics. General practitioners are encouraged to make contact with public clinics. The other members of the team already have access to , and often participate in, such clinics. The situation in urban areas is less clear, separate services often being pro- vided by general practitioners, community care workers, public clinics, and others. Here too practitioners are encouraged to use the many care services provided. Ambulance services come under the health board. Ambulances operate from hospitals located within the area and in this way can be made readily available wherever needed. The services are round-the-clock. The usual team is a driver trained in first aid and a hospital nurse from the casualty department. In severe emergencies a doctor also attends. The service has been equipped with a radiotelephone system for many years. Public clinics, under the director of community care in each area, often act as admi.1istrative headquarters for the management teams and offer a variety of services, many provided by assistant medical officers and public dentists, others by visiting consultants or paramedical personnel. Support staffing is generally by public health nurses, except where the clinic is held in a hospital. A major service is that of developmental paediatrics. For this an assistant medical officer undergoes training before carrying out the work. Other assistant medical officers have duties in school health, immuniza- tion, and other care programmes. The clinics are available in all cases for follow up. Dental officers hold clinics, sometimes mobile, throughout the board area, mainly for younger preschool and primary school children, with the main 78 emphasis at present on schools. Preventive techniques are applied universally. Usually only one session per week, or about 20% of the total work time, can be devoted to adults. This for the moment satisfies about 50% of the demand by adult card-holders. A number of hospital consultants and paramedical staff conduct clinics at regular intervals in their specialty on behalf of the health board. Cases are referred to them by general practitioners, assistant medical officers, pub- lic health nurses, and other members of the community care teams. Examples of visiting consultants are ophthalmologists, ear, nose, and throat surgeons, obstetricians/gynaecologists, child psychiatrists and psychologists, orthopaedic surgeons, and dermatologists. At present most clinic premises are neither new nor very satisfactory. To accommodate the separate consultants and other staff much physical adapta- tion and management effort has been necessary. In the present financial cli- mate this situation will not change for some time to come. Voluntary agencies in the board areas have been largely responsible for the setting up of aid centres for the handicapped. It is the duty of the director of community care to maintain a register of all the mentally and physically handi- capped. Places are allotted in various kinds of institution throughout the dif- ferent areas on the basis of the register. The voluntary agencies are then given grants and subsidies to enable them to run the institutions for the board. The mentally handicapped are graded as mild, moderately severe, and severe. Efforts are made to provide special schooling and, later , jobs for mild cases. Moderately severe patients who can be taught limited tasks are given employment in sheltered workshops run by voluntary bodies. The severely handicapped go to special centres for the mentally handicapped and, in some cases, to psychiatric hospitals. The demand for adult accommodation is still much greater than can be met. PLANNING REGIONAL HOSPITAL CA RE As has already been said, the acute hospital system is at present under- going considerable reorganization under a national programme for the de- velopment of ge1 eral hospitals. In the South-Eastern Health Board area this programme calls for a major hospital at Waterford and general hospitals at Kil- kenny, South Tipperary , and Wexford. The pace of implementing the pro- gramme will depend on the availability of resources. At present there is a regional hospital at Waterford with some 275 beds, at which certain specialties are provided on a regional basis. There are 3 county general hospitals , each with about 200 beds, which provide medical, surgical, obstetrical, and paediatric care. In addition there is a 78-bed voluntary hos- pital at Waterford. There are 11 district hospitals in the area, a number of which are mainly long-stay geriatric institutions. The others provide medical, minor surgical, and limited maternity care . Paediatric care is also provided in 3 of these hospitals. 79 There are several small private maternity homes and one voluntary matern- ity hospi ta!. In each of the 5 counties there is a psychiatric hospital with 300-600 beds. A community psychiatric service is provided from each hospital. In general, most voluntary hospitals are in Dublin, with smaller num- bers in Cork and Limerick. The management authorities for these hospitals vary widely ; some are owned and operated by religious orders, others in- corporated by charter or statute and under lay boards of governors. All but a small part of the current expenditure on voluntary hospitals is now met by public funds. A number of hospital authorities cut across the broad division of the hospital system into health board hospitals and voluntary hospitals. These include, inter alia, St Laurence's Hospital, Dublin, which is controlled by a statutory board appointed by the Minister of Health, and St James's Hospital, Dublin and the James Connolly Memorial Hospital, Blanchardstown, whose boards are representative of the Eastern Health Board and certain Dublin voluntary hospitals. In the planning of hospital care the South-Eastern Health Board set out alternative solutions. The advantages and disadvantages of these proposals were discussed at length with the local health committees and the Comhairle na nOspideal before the definite programme development was decided upon. COMMENTS (1) National overall planning can more or less be said to be "disjointed incrementalism". Whether a more formal planning system will develop seems to be largely a matter of politics. As in many European countries, the present lack of economic growth in Ireland may well afford the opportunity to look further into a more comprehensive medium-term socioeconomic plan, if for no other reason than to provide different options for future prospects. (2) The central health administration of the country has itself developed a planning unit. However, since it had only been operating for a few years at the time of the visit, the whole system clearly needs more time to settle down. Further, at both central and board level there seems to be some uncertainty as to how the whole planning and management structure should operate. (3) The central divisions are staffed by nonmedical administrators, ad- vised by physicians and other technical officers. These technical officers do indeed influence policies and programmes but could perhaps play an even greater role in decision making. As it is, while the administrative civil servants have great knowledge and understanding of the use of health resources, their epidemiological expertise is not very great. Perhaps one of the roles of the planning unit should be to encourage a change in thls, with a view to achieving better management of the new situation. 80 (4) Much of the work of the planning unit is that of an information ser- vice. It was noted, for example, that certain central divisions put up schemes, sometimes with and sometimes without the involvement of the planning unit. However, the unit has already drawn up guidelines with reference to hospital care. Perhaps it should also have a more coordinating role with other central divisions and possibly act as secretariat to the Management Advisory Committee - the chief internal group advising the Minister. In addition, it would be to its credit if it could devise practical planning models for the consideration of the different health boards. (5) At the moment the finance unit is not involved in medium-term or long-term planning. However, along with the planning unit it is developing a suitable structure for planning important input (expenditure) and output (statistical) data. This information system will only be useful when it can serve as the basis for a programme-oriented budgeting approach at both the central and board levels. (6) It would require further substantial expenditure to provide compre- hensive health and social care to existing eligible groups (about 85% of the population) while continuing to offer care to the upper income groups at cost. Furthermore, even if such provision were considered desirable, major legal barriers might need to be overcome. (7) As a consequence of more comprehensive care provision, health boards would be strengthened in their overall planning capacity because of the larger population and funds for which they would be responsible. Further, in such a system there could be better coordination between pub- lic and private dentistry - for example, public dental services could concen- trate entirely on children. (8) Great emphasis is placed on the role of voluntary agencies, par- ticularly in social care, although these agencies receive subsidies from the Government. But traditional groups such as the Church and others with high social motivation will find it increasingly difficult to obtain workers willing to be voluntary (in the sense that they accept only token payment for their work). In the long run the health boards will then have the burden of ad- ditional operational responsibility. As a result some present priorities as, for example, services to the mentally handicapped, may have to be recon- sidered. (9) There is no doubt that the new board system will greatly strengthen the delivery of health services, in that realistic regionalization has been made possible. Furthermore, links with counties have been preserved both through health board membership and through the preservation of the duties of county medical officers in the person of the directors of community care. However, closer coordination with local socioeconomic affairs would be desirable in making planning for health care delivery as realistic as possible. 81 (10) So far as could be seen, the top management at board level appears to function well, irrespective of whether its members have medical or - as is typically the case - nonmedical backgrounds. This could be due to the fact that a number of them have had great experience in local government management. (I I) The boards were not set up mainly for day-to-day management. On their establishment considerable emphasis was placed on the need for planning and on the role of the CEO and the programme managers in planning services. The inclusion of a planning and evaluation officer in most of the teams re- flected this. In reality , however, little medium-term planning has yet taken place, owing largely to the delay in getting some key posts operational. (12) Directors of community care are responsible for community services within defined areas of the board, usually coterminous with counties. It is therefore not surprising that a number of former county medical officers are appointed as directors. Nevertheless, many posts still remained to be filled at the time of the visit. Perhaps one reason for this lies in the fact that county medical officers are approaching the end of their careers. Also, the post re- quirements call for managerial, planning, and leadership skills to a larger ex- tent than was needed for county medical officer posts, where all the major decisions were made by the Department itself. An additional reason may be that the salaries do not compare favourably with those of other medical specialties. A solution for the immediate future could be inservice training, partly by the health board itself and perhaps through the new faculty of com- munity medicine just being set up. To this could be added as an incentive pay- ment at specialist rates. (I 3) New recruitment for director posts presents a problem, since the career structure for assistant medical officers is very limited. Also, many of these medical officers are engaged in clinical work, e.g., tuberculosis and paediatrics, and often they prefer their clinical work to administration. How- ever, health boards could consider paying stipends to assistant medical officers for a study course in community medicine, with the understanding that it could lead to career advancement in time. This should afford opportunities for moves upwards as far as posts of programme manager, as long as there was no discrimination against nonmedical personnel looking for the same job. (14) A similar problem arises in respect of dental officers. They have no prospect of becoming directors of community care, although there are senior dental posts under directors. Perhaps consideration should also be given to their managerial qualities. Environmental health, now the responsibility of a director, could be delegated to a senior assistant medical officer. It is possible that the blocked career is one of the reasons for the Dental Association's dis- couraging attitude towards public dental officer posts. (I 5) The multipurpose public health nurse is one of the most successful features of the health services in Ireland. She carries out many duties that in 82 other countries would be performed by several health workers, including the physician. The attraction of the training programme to young women 'aS well as the popularity of the public health nurse in the community are es- pecially noteworthy. The public health nurse is also the key to community care delivery in that she cooperates with general practitioners, consultants at public clinics, social workers, and others. One weak area, however, is her lack of contact with the hospital services. (16) The position of the general practitioner as an independent contractor to the health boards for medical card-holders has certainly enhanced his finan- cial status as well as given many more of the public a free choice of doctor. It is said that this has greatly improved general practitioner services, but there is very little information available either for or against this assertion. The only information as to performance at present is a comparison of the individual doctor's consultation rate with the board and national averages for these. The same comparison with regard to cost of prescriptions is also of limited value. Problems have also arisen with immunizations because the practitioners feel that the fees are too low; when a practitioner carries out an immunization, he often even neglects to forward the record to his board. (I 7) The College of General Practitioners could aid the boards greatly in their planning by encouraging and analysing information from general practi- tioners with regard to morbidity and the utilization of services. In the South- Eastern Health Board, and doubtless elsewhere, pilot efforts to involve general practitioners more closely with public community services seem to be slowly bearing fruit. The dispensaries, if maintained and enlarged, could still perform a useful function for care delivery groups including general practitioners, public health nurses, and social workers. (18) From the above it is obvious that the various management levels in the boards are more closely integrated than the various central divisions. Each of these still promotes its own vertical programme. More recently, there have been attempts at better coordination. (19) One o r two points may be raised about the services supplied. Fluorida- tion of water supplies has met with general acceptance. The employment of den- tal auxiliaries to do work in the mouth could also be considered. Occupational health services exist only on a private basis in major establishments . It may be worth while for community care services to provide such services in the future, at least to some extent. With regard to other services, the number of screenings in schools seems somewhat excessive , ·vhereas screening of the elderly could be done more systematically. There seems to be a need also for health education in community care, judging from the high use of alcohol and tobacco. (20) Safeguards should be introduced to ensure that the overall pro- gramme for community care will not be impaired by the hospital services. 83 There is a danger that a growing share of the budget will be needed merely to maintain the hospitals already functioning. It would seem desirable to establish medium-term plans for community care. These could also show how, with improved community care , the growth of the hospital sector could be con- tained without harm to the population. (21) In preparing such plans, economic evaluation (for example, cost- effectiveness assessment) should have a prominent role. Such evaluation should cover not only the internal economy of the health sector but also its relation- ship with the economy as a whole, e.g., as regards the creation of employment. (22) Planning itself has in the past often been entrusted to outside consul- tants. While this has its advantages, especially with regard to advice on organ- izational structure, it does not adequately develop skills and expertise or motivate key administrators and their associates. lt would, therefore, seem that internal planning with full participation by administrators, managers, service providers, and service consumers would, although slower initially, create understanding, learning, and motivation. 84 Annex I VOLUNTARY HEALTH INSURANCE SCHEMES A. The hospital scheme The benefits are as follows: Maintenance units provide cover against hospital or nursing home main- tenance. The benefit payable is £2.10 per unit per week for each adult or child, as long as necessary, and the maximum weekly benefit payable is this amount multiplied by the number of maintenance units selected. One treatment unit covers any of the following : operating theatre fee - 50p to £1.50 per unit depending on the classifica- tion of the operation surgeon's fee - £1.00 to £14.00 per unit depending on the classification of the operation anaesthetist's fee - £1.00 to £2.50 per unit depending on the classification physician's fee in nonsurgical cases (for a period of 6 days or less) - £1.50 per unit hospital stay for more than 6 days - 25p per unit per day (annual maxi- mum £22.50 per unit) other in-hospital charges : X-rays, pathology, consultants , blood, ECG, and similar charges - annual maximum £25.00 per unit drugs and medicines - charges in excess of £3.00 (annual maximum £25.00 per unit) special nursing - annual maximwn £25.00 per unit. Some of these benefits apply also to selected outpatient schemes. The annual subscriptions for individuals per unit are 58p per maintenance unit and 87p per treatment unit. The costs are somewhat less for children and somewhat more for the elderly. B. The home scheme The following areas are covered by the voluntary health insurance home scheme : general practitioner services specialist consultations, investigations, and treatment anaesthetics 85 operating theatre radiology pathology physiotherapy by a qualified physiotherapist when necessitated by acci- dent or illness ambulance charges drugs and medicines home nursing surgical and medical appliances deep X-ray therapy. Payment is made in respect of eligible expenses in excess of £35 per an- num per single person and £50 per married couple, in the amount of 80% up to £300 benefit, and 100% thereafter up to £500 maximum benefit. The following subscriptions apply per annum : Single person Child Married couple without children £3.00 £1.50 £6.00 An additional subscription of 50p per year is charged for each person aged 60 years or over. 86 Annex 2 THE GENERAL MEDICAL SERVICES (PAYMENTS) BOARD It is the duty of the Board to perform on behalf of the health boards the following functions in relation to the provision of services by general medical practitioners and pharmacists: (a) the calculation of payments to be made for such services; (b) the making of such payments; (c) the verification of the accuracy and reasonableness of claims in rela- tion to such services ; and (a) the compilation of statistics and other information in relation to such services. The Board consists of 11 members comprising (i) 1 officer of each health board designated by the chief executive officer of that board and (ii) 3 other persons appointed by the members referred to in (i). At 31 December 1975: (1) 1270 doctors and 1145 pharmacists were registered under the scheme. Of these, however , 69 doctors and 43 pharmacists were not actively participating. (2) The number of persons covered by the scheme was 1162 386. (3) The amount paid in fees to participating doctors was £8 799 708. (4) The amount paid for medicines was £15149 576. (5) The overall payment per panel patient was £21.93. (6) 76.75% of persons on their panels received services from doctors paid by fee. 87 III AUSTRIA : THE TYROL DH.S. Griffith 1 & H.F.K. Zb"/lner2 In Austria and, as will be seen, in the Federal Republic of Germany, provinces or states rather than the whole country, because of historical, geo- graphical, or political reasons, tend to be the centres for developmental effort. The description of and discussion on Austria perhaps , therefore , accentuate the role of institutions not mentioned elsewhere ; more allusions are made to mixed private and public socioeconomic effort and the context is smaller than for some other countries. Nevertheless, the pattern displayed has as much relevance to health and development activities as have examples from other, dissimilar regimes. Austria lies in the heart of central Europe, sharing boundaries with 6 coun- tries: Czechoslovakia, the Federal Republic of Germany, Hungary, Italy , Switzerland, and Yugoslavia. Its territory is 92% mountainous and its popula- tion in 1971 was some 7 .5 million , of whom more than 1.5 million lived in the capital, Vienna. The country is a federal republic, thus possessing both federal and Land (provincial) governments, the latter having very considerable autonomy in the running of their affairs . Broadly speaking, the Federal Government is responsible for such matters as foreign relations and the customs service. In the health field it runs public health laboratories, protects the environment, and assesses the quality of food and drugs. The Federal Ministry of Health also engages in policy formulation, the drafting of laws , and supervision of training. Towards the Lander its role is that of coordinator and adviser rather than director or controller. 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Copenhagen , Denmark . 2 Health Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 89 The country's health status resembles that of many others in Europe. The birth rate is around 14 per 1000, the death rate more or less static at I 3 per 1000. The principal causes of death are cancer, cardiovascular diseases, and accidents. By contrast to the "deductive" method of planning in centrally planned health systems, an "inductive" method is employed in Austria. In accordance with the principles of federalism and social partnership, regional and local planning teams investigate conditions at the regional and local level, and it is on the basis of their findings and recommendations that action is taken to remove defects and improve matters step by step. Thus, through optimization of the subsystems, improvement of the whole system is achieved without need to resort to central control and guidance. REGIONAL PLANNING IN THE TYROL One of the functions of the 9 Lander is socioeconomic planning. This is illustrated by the Tyrol, of which the capital is Innsbruck (population l l 5 197) and the overall population 540 771. It lies mainly along the mountainous valley of the river Inn . It is important first to understand the nature of the Land government. Headed by an elected governor representing the majority political group, the Land is required both to implement federal Jaws and to legislate on its own behalf. It is obliged, therefore, to follow nationally agreed guidelines in some respects, but in others is able to follow its own policies. One such programme is that which in the Tyrol is called regional planning, although what constitutes a region in the Tyrol does not necessarily correspond to the description more generally assigned to the name. Planning for socioeconomic development on a provincial basis has ex- isted in the Tyrol for a number of years. The system, however, was not very satisfactory. Political parties, in formulating their policies , put forward mani- festos as party plans which, when they came to power, became government plans. At the same time the civil administration and the scientific community also developed independent plans. None of these plans was totally acceptable to the others. In January 1971 a regional planning group directly attached to the Gov- ernor was set up in the Tyrol. This group has the following functions : (I) to advise the Governor on matters of regional planning, which is a direct responsibility of the Governor himself (this includes the assessment and forwarding of specific sectoral plans) (2) to form a secretariat for the various bodies concerned for planning purposes (3) to coordinate and centralize the statistical infonnation necessary for regional planning and to make it generally available 90 (4) to promote closer interdepartmental collaboration within depart- ments of the provincial government (5) to prepare various analyses of the socioeconomic status of the dif- ferent subregions within the province. In February 1972 a law was passed by the provincial government giving a formal mandate to the Governor to set up appropriate machinery for re- gional planning. Some of the concepts behind this machinery are : (I) Planning must serve man (rather than compel him) by stressing social welfare as being of higher priority than pure growth of the economic infrastructure and productivity. (2) To facilitate the impact on overall welfare, planning must coordinate the development efforts of the various departmental groups within the provin- cial government. (3) Official bodies must be set up, consisting of politicians, administra- tors, and scientists, to foster agreement on joint efforts to develop plans. (4) The official bodies must operate not only at provincial level but also at subregional and local level. (5) These planning groups at all levels must maintain a continuous ex- change of planning ideas, suggestions, and needs. This will achieve a better acceptance and easier implementation of mutually agreed plans. In other words, this will constitute "two-way flow planning" (TWFP). (6) An information system must be set up that will continuously generate the relevant indicators of planning needs, objectives, and targets in particular but also continuously monitor and evaluate implementation performance. This will permit prompt adjustments in the execution of the whole or any individual portion of the plan or planning process. The machinery for planning The structure set up to carry out the concepts outlined above consists firstly of the conference. Conferences are found at three levels, namely, na- tional or federal, provincial or Land, and subprovincial. These bodies are pol- itical organs that endeavour to guide policy at the different levels and to foster the establishment of agreed plans and plan implementation. The second body, also to be found at the various levels, is known as the council . Each council is composed of politicians, civil servants, and scientists, and the chairman is not a politician but a civil servant. The councils have the duty of setting up special expert committees that examine all and any special- ized areas of planning interest. One of these committees is concerned with health matters. The head of each expert committee is a politician who has specialized knowledge in the field concerned. 91 An expert committee studies the field assigned to it, prepares a report, and makes recommendations . These are transmitted to the council, which may accept, modify, or refer back the proposals. Accepted proposals are consoli- dated and forwarded to the appropriate conference for approval. Depending also upon the level at which the proposals origina te - and they may originate at any level - they move to the other levels , where again they may be referred back for review until such time as final agreement is reached at all the relevant levels . In most cases the highest relevant level as specifically laid down by law is the Land. At this stage the proposals, which in fact are part of the overall evolving plan, are passed to the normal legislative and execu- tive channels for final acceptance and funding. It should be emphasized that the socioeconomic development planning bodies do not constitute a govern- ment within a government but carry out their functions within the normal legislative and executive context. Such planning can therefore be seen to be genuine regional planning within the bounds of the whole Land, rather than a macroplan devised mainly at the provincial level itself. In the matter of regional planning the Tyrol has taken a lead in delineating regions within the Land that are not necessarily administrative subdivisions. These subprovincial entities for planning purposes are characterized in certain specific ways. They must possess a minimum planning viability of their own, which is not necessarily identical from region to region. Thus, one region may have been delineated on the basis of its homogeneity as a tourist region or on the basis of its socioeconomic nodality, while another may have been defined as an urban/rural agglomeration. For special-purpose plans many of these re- gions may have to be pooled in order to constitute a suitable planning entity for the particular requirement. Thus , a hospital plan would certainly call for a combination of the smallest regions that have been officially designated as planning regions for other purposes. The rationale of this rather complex planning structure is to balance the development of overloaded urban areas and relatively backward rural and mountain areas so as to increase the social and economic development poten- tial of the Land as a whole . In all, 55 regions have been designated for planning purposes. Each of these has been equipped with the appropriate planning bodies. A major advantage of the system just described is the active participation by politicians not only in their traditional role but as leaders of specialized expert groups within the regional planning structure. Thus they are able to promote and adopt plans in their own areas which, in part at least, are their own brain children. It means also that they can much more readily mobilize the general population (i.e., the consumers and private production interests) for such plans than civil servants and administrators have been and are able to do. A second advantage in the planning machinery is the commitment of scientists, administrators, and politicians to the planning. The machinery in fact enforces a certain discipline on them, and in particular requires and fosters continuing participation by politicians regardless of their party af- filiation. The system, which is now in operation, can therefore be expected to con- tinue to function under almost any circumstances. 92 It must be stressed at this point that the system is relatively recent. However, it has already gained considerable momentum. For example, an investment programme for eliminating traffic bottlenecks, covering the period 1973-1978, was agreed upon by the regional planning bodies and awaits final sanction , and the finding of about 1000 million schillings ($53 475 936), by the legislative authority of the Land. No major obstacles are foreseen in obtaining either the sanction or the short-term funds. With reference to funding, the Land does not - at any rate for the present - have any other budgeting system than the yearly allocation of funds. However, for the encouragement of private initiative, longer- term allocations are already being made available within the present yearly budget. For example , to promote tourism in certain areas, the Land may sub- sidize interest charges for the construction of hotels and similar tourist facilities . For this purpose the entire amount of the subsidy, say for IO years, is made over to a private bank less a discount factor. It is then the responsibility of the bank to provide an eligible entrepreneur on , for example, a yearly basis, with mortgage or interest subsidies to assist him. This is an instance of public sup- port for private enterprise ; more direct measures, such as public construction of industrial buildings for private use, are not envisaged. It can be seen that present planning is of the sectoral project/programme type. However, the machinery has not yet been long in motion. Different sec- tors are now coordinating through the regional planning bureau. Of major in- terest to the health sector has been an initial approach to hospital planning (the MEDIPLAN), of which more will be said later. The planning method is not based on macroeconometric models, that is, there is no model permitting maximization of the return on economic invest- ments or, in other words, of economic growth. Instead, it is true regional planning in that the analyses undertaken permit the setting of priorities not only by economic sectors but also by social sectors and geographical areas. In order to analyse each region and to provide the various bodies with basic information and indices , the Land bureau of regional planning has created an information system. The data collected include considerable information on the social and economic status of each planning region. The information is published for other users and is used for specific analysis by the bureau itself. One such analysis divides the raw data fust into 22 socioeconomic indicators. Subsequently these are reduced considerably in number and several principal component factors are arrived at, including economic activity, environmental quality, health services coverage , and recreation . These factors were first com- pleted for the year 1960 and then for 1970. For each of the years the factors were then ranked in accordance with their factor scores. This gives a readily understood index of areas of concern, both geographically and by social and economic sector. In order to project the likely trends for the future and the potential im- pact of different investments, simulation models of a dynamic nature are being developed. In other words, feedbacks are introduced which, under certain outcomes, will alter the consequences of the simulation. The models do not attempt to optimize, i.e., select the most efficient investment, but instead set out a number of options together with their likely consequences. These are then presented to the planning authorities as an aid to decision making. 93 Once a particular investment package has been chosen for implementation, the model or models can then be used to guide monitoring and evaluation. Planning in the Tyrol has already been stated to be in its early stages. How- ever, with the evolution of the techniques and machinery now in operation it is possible to foresee within the not too distant future the development of a com- prehensive medium-term (10 years) planning system. Furthermore, by carrying out analyses and setting up machinery on a pragmatic basis and by learning from mistakes before first formulating goals and objectives, the Tyroleans believe that they will be able to reach decisions more quickly on specific targets and investments than has been the experience elsewhere in the country. RELATIONSHIP BETWEEN THE OVERALL SOCIOECONOMIC SITUATION AND HEALTH PLANNING Regional plans and their aggregates have had to take into account the need for local community-based services and for services such as hospitals that serve larger population groups. Fortunately these community plans have been able to take into account the existing distribution of physicians and other staff throughout the province. Similarly, the public health structure is able to adjust to overall planning without extensive disruption, although changes in the health problems and health care of the population will of necessity alter the methods of provision of care. The organization of community care depends largely on independent doctors. The organization of hospital care depends to a greater extent upon the Land itself, because it is the Land that operates the hospitals directly. It must always be borne in mind that, however independent the medical practitioners are and to whatever extent the hospitals are controlled by the Land, they always have been, and always will be, part of the total socio- economic planning of the Land. The place of the Chamber of Commerce in regional planning Systematic planning is of recent origin and, as post-war reconstruction needs were more or less obvious, planning was mainly in the form of ever- changing party platforms and "technocrats'' were hardly involved. The Chamber of Commerce faced public resistance when it embarked on regional planning studies for each district in 1967. Now the opposite situation, if anything, pre- vails: the public sees forecasts as magic that must come true. A new series of regional planning analyses is now being prepared for each district, including (usually 5-year) forecasts for the population by age groups, in- come opportunities, opportunities for sectoral growth, and the derived needs for manpower and investment. Policy suggestions are then made for education and training of local manpower and for attracting tourists, industry, etc. lnput- output, demographic, and growth rate methods are employed. The reports are published in simple language to enable schools to use them as teaching material. 94 The Chamber participates actively in the council for regional planning, especially in the delineation of regions, development of the regional infor- mation system, and development of industries, commerce, and tourism. The newest slogan is "quality of life", and the Chamber will be more involved with the health sector. It has now become engaged in forecasting the likely load on the health services. THE HEALTH INSURANCE SYSTEM The sickness fund or insurance is that part of social insurance concerned with health. The fund is composed of several societies, e.g. , of railwaymen and federal employees, which administer health insurance . The area sickness fund is by far the largest. A detailed description of this and of other funds may be found in J. Hogarth.a All social insurance is compulsory . Contributions are shared half and half between employer and employee. Contributions to the sickness fund depend on income levels and probably account for more than 7% of the worker's income on average. There is no subsidy from the State except for maternity. The fund covers the insured worker and his dependants and gives benefits in cash and in kind. An example of cash benefits is the maternity allowance. Health ( or rather sickness) insurance given in kind provides that the insured persons and their dependants shall be treated free in most cases except for a nominal charge, both as ambulatory patients and as hospital inpatients. Ambu- latory care is mainly in the hands of independent contracting practitioners, while inpatient care rests with salaried hospital doctors. Included in treatment are dental care and drugs. There is free choice by the patient of the physician, in so far as the patient , when desiring any consultation, obtains from the fund a treatment form covering a period of one quarter of a year. He takes this to the physician of his choice and remains with that physician for the rest of the quarter for all care, unless he is referred to a specialist or receives the approval of the insurance fund to change his physician . Specialist referral is permitted and may be either to an independent specialist , who does not have hospital beds but is nevertheless under contract with the insurance fund, or to a salaried hospital doctor, who is paid by the Land or Federal Government. A patient also has the right to obtain treatment from an independent specialist directly, but not from a hospital physician. In the Tyrol the payment of the physician is on a fee-for-service basis. Each doctor is obliged to record on the treatment form the consultations held , drugs provided, injections given, and so on . All the items of service are con- solidated each quarter and the doctor is paid according to a tariff of fees fixed a Hogarth, J. The payment of the general practitioner: some European comparisons. Oxford, Pergamon Press, 1963. 95 by negotiations between an insurance body covering most of the insurance funds and the representatives of all the contracting doctors of the Land. The tariffs are reviewed and adjusted every year. Payment by the insurance to the hospitals is in the form of a lump sum per case. Additional hospital costs over and above those paid by insurance are met by the hospital owners with the help of federal contributions of up to nearly 20% of operating costs. The hospital owners may be communes, singly or in groups, or the Land itself. Three important factors in insurance and health care delivery should be noted here. First, the fund is a sickness fund, sickness being defined as an ir- regular condition of body or mind that makes medical treatment necessary. Thus a condition that is unresponsive to treatment is not a sickness entitled to benefit. Second, hospitals are limited in the outpatient services they may per- form; outpatients may attend only after referral, for follow up, or in emerg- ency. There is no open-house outpatient system. Third, the insurance funds maintain their own medical advisers to act as a check on potential abuses of the services provided by contracting physicians. PHYSICIANS AND THEIR PROf'ESSIONAL ASSOCIATION IN THE TYROL There is a professional medical association for the whole of Austria called the Arztekammer (AK). This representative body is elected by the mem- bers of the association and committees are found at national and provin- cial (Land) levels. Each provincial committee has a dual function , one professional, the other economic. Under the heading professional come such matters as phys- ician registration, discipline , and ethics. The economic role, besides manage- ment of a pension fund for members, includes a number of other activities, namely: (a) negotiation with the social insurance body on reimbursements and fee scales; and (b) agreement between the AK and the social insurance body on the location, numbers, and specialties of physicians operating under the in- surance contract system. All the above functions (and others) are prescribed by federal law. It should be noted that over 90% of independent physicians are engaged in some kind of insurance work. There is a legal requirement for all doctors to register at some time or other. The AK maintains a register of two types of independent physician and a register of hospital physicians. The types of physician are as follows: (a) newly qualified doctors undergoing internship training in hospital; (b) general practitioners, i.e., physicians who have completed 3 years of hospital training; and (c) specialists who have completed 6 years or more of formal training in their particular specialty. 96 A hospital physician is one who is either a trainee for a specialty or who has passed the necessary training requirements as a specialist and is then fully employed by a government hospital. He is a salaried physician, usually with no right to independent practice.a Physicians working in full-time departmental situations, i.e ., as public health officials, are not found on the AK register , nor are those belonging to the armed forces. The numbers of these are small . Independent physicians form by far the largest group of doctors. As has already been mentioned, an overwhelming majority contract with one or more sickness insurance schemes to provide services to the insured and their families . Independent physicians are classed either as general practitioners or as special- ists. The insured have access to either group at their own free choice, without necessarily being referred from one to the other. A number of general practitioners also carry out certain public health functions under agreement with the public health authorities. This is at the lowest administrative level - the commune - and they are called community physicians (Sprengelarzt). The Sprengeliirz te come under the district authority and are paid by the district health officer (Amtsarzt) . They receive their funds from the Land public health department as full-time health officials. Besides the community physicians, a number of practitioners carry out part-time school health work in secondary schools. They are paid by the ap- propriate school authority. Some independent specialist physicians enter into agreements with the hospital authorities (commune or Land) to engage in part-time inpatient work in their specialties. A number of these, e.g., anaesthetists, radiologists, and gynaecologists, are in fact given the status of part-time hospital consultants. Payment is by lump sum on a sessional basis. These physicians, however , like all other independent physicians, practitioners, and specialists, are not per- mitted by law to use hospital outpatient facilities. This work must be done within their own practice only _b When a physician is unable to deal with any particular patient, he can refer him either to an independent specialist or to the hospital , where he will be seen by a full-time salaried hospital doctor. Patients are also, within the system, referred back again. One other item of interest in services provided for outlying areas is the house pharmacy. Here a doctor is licensed to stock drugs and supply them until such time as a full-time pharmacy becomes available in the area . a A very few do have the right o f independent practice . They are the most senior and are heads of departments. b Anomalous situations have arisen because of this system . For example, a qualified specialist was asked to operate a new X-ray machine in a hospital. He refused a full-time salaried position, but consented to act as a part-time consultant. He subsequently pur- chased his own X-ray equipment and used it in his own practice , so making the best of both worlds. 97 It can be seen that there are considerable differences between the various groups of physicians, depending on their actual work. Thus no general practi- tioner or independent specialist, except as stated above, can have beds in a pub- lic hospital. There is, however, nothing to prevent them from having beds in, or even owning, a private hospital. Of the latter there are very few in the Tyrol. It is the policy of the AK to promote independent practice wherever pos- sible. In addition, the AK encourages modernization of all independent practice, for example, by the addition of clerical and paramedical aid. For specialists the AK is promoting the acquisition of improved equipment and medical support facilities. However, it feels that insurance fees are too low to permit such modernization and support at present. The AK for the Tyrol has little expectation that group practice will be very prominent during the next 10 years, believing that it will be feasible in cities like Innsbruck only. Construction firms have offered to build group practice premises and have been turned down on several occasions by in- dependent physicians. Although, as noted above, a certain amount of personal preventive care is provided by school and community physicians, the AK believes that, while it is widely spread, it is not yet very systematic or adequate. While smallpox vaccination for children is insisted upon by law and BCG vaccine is given as a routine to all babies delivered in hospital (probably about 90%), other im- munizations do not seem to have been carried out to the same extent. The AK would like to see its members and others working towards a regular immuniza- tion schedule. In another field, that of maternal and child health, the AK at federal level has cooperated with the Ministry in promoting preventive care. Mothers who have the recommended checks during pregnancy are given a double childbirth allowance. A further condition of payment is the attendance of mother and child for postnatal and well-baby care. The Tyrol AK is also anxious to sponsor this service. The question of screening for different diseases, mainly cancer, is at present under discussion. In Vorarlberg a successful programme has been conducted by independent practitioners, while the federal Ministry is now conducting a pilot screening project in Vienna and Karnten with the aid of private physicians. The social insurance schemes have already been asked to devote 2% of their ex- penditure to such preventive activities. The whole question is due for study by the expert group for health within the regional planning structure already des- cribed. One of the major obstacles seems to be the allocation of the costs of such preventive measures among federal, Land, and insurance bodies. A large amount of data on planning in relation to manpower is available at the AK offices. This should not, however, surprise anyone when the registra- tion, practice allocation, and pension functions of the AK are considered. In effect, it would seem that the AK and the insurance body have been the major health planners in Austria for many years. At present, planning for independent physician manpower rests entirely with the AK and the insurance body. The main planning analysis is by the AK, which keeps, among other data, up-to- date information on doctors regarding numbers, locations, specialties, vacancies, insurance contracts, consultancies, and the like. This has been easy because of 98 the need to administer the physician pension fund - a very important source of physician data. The planning method used for independent physicians is based on such factors as population, tourism, hospital availability, and exist- ing physician manpower. For general practitioners the main criterion is a popu- lation of some 2000-2300 (including full-time equivalent tourists in terms of resident population) per general practitioner. Planning for independent specialists with insurance contracts continues to present difficulties for certain specialties, mainly those which involve surgical procedures. Hospital consultancies are scarce and there are more specialists than can be fitted into the hospital system. One other problem for planning, according to the AK, is the fact that the Tyrol is an attractive area for graduates of the medical school in Inns- bruck, irrespective of their own former domicile. In consequence the demand for jobs is in excess. This has led to the situation that only four additional general practice posts can, according to the AK, be made available during the next year. In view of this situation, the AK is already warning high-school graduates not to study medicine. The AK is already represented in the expert regional planning group dealing with health. Besides the earlier mentioned discussions on preventive care, the distribution of dentists, the hospital plan , and the location of general practitioners are all due for review by the expert group. There has, h?wever, not yet been enough time to integrate the AK and the regional planning bureau data. THE PUBLIC HEALTH SERVICES The Bureau of Public Health Services is one of five departments under the control of the Deputy Governor of the Tyrol (Fig. I). It is mainly responsible for the organization of public health services within the Land. The main executive functions for public health rest with a number of physicians at an intermediate administrative level , the district. Here, under the overall control of the district governor, is the Arntsarzt, or district public health officer. He can be said to be generally guided by the chief district ad- ministrator and supervised technically by the Land health division. The Arntsant is a Land employee. His pay is 25% less than that of the administra- tors. There are 6 Arntsiirzte for Innsbruck and 13 in the rest of the Tyrol. His functions include legal matters related to public health, supervisory, organiza- tional, and control activities, and several matters concerned with personal health care. He is allowed to do private work outside office hours. Under his legal functions come a number of duties including food and drug control, the licensing of poisonous substances, and the maintenance of legal standards for the operation of hospitals, hotels, etc. His supervisory, organizational, and control activities include medical examinations for drivers, those due for premature retirement , foreign workers, hotel workers, public service applicants, and paramedical personnel, and the 99 0 0 Fig. 1. Outline of public health and hospitals administrati ve structure in the Tyrol LAND GOVERNOR Regional Planning Office Deputy Governor Social and Health Affairs .. I Other deputies Personal Secretary to Chief Administrator Lands Arzredirector -------(Chief Administrator) Bureau of General Social Welfare (TBC, drugs, handicapped , disabled) Bureau of Youth Affairs Sprengel midwife (part-time) Funds for TBC programme Bureau of Publ ic Health Services Bureau of Social Insurance and Regional Affairs Bureau of Hospitals / Un iversity Clinic District Amtsarzt Part-ti me consultants Other Land 1 : 25000-30000 - ----for ortho~aedics / hospitals population and paediatrics / / BCG to infants TB specialist 1/ - 1-- ---a-nd mobile X-ray Sprenge/arzt (Community Physician) (part-time) 1 : 2000- 3000 population Food & drug control officials legal enforcement of smallpox vaccination and other duties connected with communicable disease control (this caJling for vaccination between the ages of I and 3 years). Duties concerned with personal heaJth care include organiz ing and operating voluntary vaccination programmes for BCG , DJYf, and poliomyelitis ( usually carried out in schools by the Amtsant himself) and organizing by subcontract district teams for maternal and child heaJth (MCl-1) (mother counselling and free vitamin D and flu oride tablets) , tuberculosis screening including X-ray, orthopaedic care of the handicapped, and paediatric advice on handicapped or disturbed children. The Sprengeftirzte (SA) These are independent general practitioners who are also part-time public health officials. They come under community administration and are tech- nically supervised by the Amtsarzt with respect to their community function. There are about I 02 planned posts outside Innsbruck city, aJI of which appear to be f11led. Each SA covers a population of 2000-3000. The SA's public duties include: (a) the provision of physician and midwife care for all sick persons and pregnant women: (b) control of the quality of water and sanitation; (c) policing functions with regard to structures and buildings of all kinds, including mortuaries and undertakers' premises; (d) supervision of welfare and aJI other care services for the handicapped and the disabled who are not in public institutions ; and (e) primary school medicaJ care. The Sprengel midwife (SM) The SM is a qualified midwife who has undergone 2 years of training under a federal teaching programme and has an independent midwifery prac- tice . Like the SA , she is a part-time employee of the community. She is under the technicaJ supervision of the Amtsarzt and is guaranteed a minimum income from Land funds. Her public functions are to counsel expectant mothers and to follow up postnatal women and their babies, whether delivery has taken place at home or in hospital. She can discharge part of this duty as a member of the district MCH team. The budget of the public heaJth service in the Tyrol for 1972 was about Sch. 7 000 000. This excludes the salaries of the Amtsiinte and the Land contribution to the SAs, but includes payments to the SMs. Other exclusions are the fed eral contribution to the cost of vaccines (a high contribution) and of fluoride tablets (a token contribution). To give an indication of the relative magnitude of expenditure items, Sch. 530 000 are spent for school heaJth and Sch. 2 600 000 for subsidizing the 140 SMs. 101 Public health statistics returns go directly from communities and districts to the central bureau of statistics in Vienna. Here data are processed but may not be returned until as much as 2 years later. Social welfare and public health work do not seem to be very closely related. The health officials have legal functions, for example , they can require an individual to enter an institution, but their social welfare functions are mini- mal. Equally, while the social welfare authorities have responsibility for reha- bilitation and for operating various welfare institutions in additon to what they do through community workers, they seem to have little contact with the medical profession. One or two suggestions fo r improving the situation have already been under discussion. Thus, it is the intention as far as possible to re-educate midwives with the aim of giving them much wider social welfare functions. Another suggestion was to create a cadre of specialized community and geri- atric nurses. To improve the quality and extend the coverage of preventive personal care , it is planned to create an association combining federal, state, and in- surance contributions whereby more funds will be made available to give incentives to community personnel to provide better services. This implies the upgrading not only of the SMs but also of the work of the SAs. Some thought , both in the Land and in Vienna, has been given to re- training and reorganizing the various cadres. Training of the Amtsant has been conducted under a law now I 00 years old . It calls for 2 years' work in hospital followed by the equivalent of6 months of full-time training. The Amtsant then passes an examination conducted by the chief Land public health official. WHO has assisted in devising a change in future training and in personnel. It has been suggested that all t raining should be done at a federal institution on a full-time basis fo r l year. The same institute would also train public health nurses and public health inspectors. During the second semester all 3 groups would train together as teams. The team approach has been success- fully tried out in I area in Austria. It has also been suggested that a second grade of Amtsant be created from the Sprenge/ant. They would receive a payment in cash - in place of the l /8 actually taken as pension contribution - and also take a mandatory course lasting 2-3 months. To assist the SA there would be public health nurses stationed in the villages. They would be state-registered nurses with 400 hours' additional training, and part of their function would be to care for the sick and old and to supervise unskilled home helps. HOSPITAL PLANNING - MEDIPLAN As might be expected, the prov1S1on of hospitals, being a duty of the Land Department of Health and Social Affairs, calls for systematic planning. As a consequence, the deputy governor in charge of health and social affairs, 102 like his counterparts in Ireland and the United Kingdom , made use of a group of independent consultants, which produced a plan called MEDIPLAN. Brieny, MEDIPLAN examined the present situation and produced fore- casts up to 1990 that took in to account population and possible changes, bed occupancy, changes in the delivery of hospital care, continuance of the same kind of ca re, the int roduc tion of efficiency measures (e.g., moderniza. tion and degrees of intensive care), and bed/staff ratios in university and non- university hospitals. The report of the consultants recommended: (a) the construction of individual hospitals; (b) the pooling of hospital management in areas; (c) centralization of the laboratory and pharmacy services ; (d) a central comprehensive health service information system; ( e) the utilization of additional hospitals for the training of physicians; (J) the training and retraining of technical staff on a larger scale; (g) active (community) geriatric and rehabilitation care; and (h) the charging of flat rates. COMMENTS It is obvious that the health care system has developed its own pattern over the years and has built up a reasonably systematic structure for the provi- sion of care for all. What has been lacking in the past has been a machinery for making the system more critical of itself. The main innuence in this field will come from the planning system that has been set up, rather than from the health care system that exists at present. There are a number of fundamental problems associated, for example, with the insurance sche me that will be solved only when the insurance body is more involved with planning groups, manpower assessment and placement, and data inputs from the scheme into the planning process. As a means for operating a community service, insurance schemes have both advantages and disadvantages. The insurance system must be self-supporting, therefore it is obliged to set a ceiling on its fees for services. If the fees are unsatisfactory the suppliers of service can opt out, as has already happened in the Tyrol with the dentists - about half of whom are qualified doctors0 - who have achieved such independence that they have been able to reject the a There are I 00 dentists with and 110 without a medical degree. All dentists be• ing trained will eventually possess a medical degree. Dental aides are not permitted to touch teeth. 103 insurance system. According to their view, an increase of about 67% in the present tariffs would be necessary to enable them to make a reasonable living. For physicians the case is somewhat different. With 1 doctor on average per 500 population there is a fair degree of competition, although there are more compensations from tourism than dentists have. In order to begin prac- tice - except for those destined for the academic world - it is essential for them to make a contractual arrangement with at least one sickness fund. Furthermore, the AK and the fund permit contracting only where they con- sider there is a place for yet another physician. Thus the doctor is not so independent that he can tum away insurance work altogether (although in fact it has been done from time to time). Tariffs can, therefore, be applied rela- tively more easily. Insurance practice is thus ensured . Of course, the physician, once installed, tends to rely gradually on private work, largely from tourism. On average this will give him about 50% of his gross income. However, for the present at least the insurance doctors cooperate with the sickness funds and rely on the powerful AK, which is highly experienced in negotiation and manpower placement, to look after their interests. In the long run the losers are the hospitals and the public at large. Hos- pital costs increase faster than do their insurance payments. Worst off are the public, who must not only increase their premiums but also pay off hospital deficits out of general taxation. The sickness insurance scheme is obliged to keep records. A wealth of in- formation is available to them and to others on both the outpatient "chit" system and hospital and insurance inpatients. While some information is com- piled on utilization and other data about inpatients, little attempt is made at analysing it either medically or actuarially. Nor is there any epidemiological forecasting, a prime reason for this being shortage of manpower - 12 clerks do all the work manually.° Funds are not available for computer operations. The most important managerial analysis is that for drug prescriptions, carried out to check extravagance by physicians. Fortunately all records are retained for 5 years, so that retrospective studies should be possible. The executives of the insurance body, well informed as they may be of current and developing situations in the health field, can be tied by the nature of sickness insurance law. An interesting experiment in rehabilitation is going on at Hochzirl. However, as it involves a number of cases of chronic and "pen- sioner" illness, the insurance system has been unable to give it support, despite the fact that it might well save money for the funds. This seems to suggest a gap between the general management and its medical advisers. The law and the type of insurance system based on sickness make preven- tive action almost impossible. A recent law, however, requires the funds to devote 2% of their income to preventive work. In the mean time , apart from the subsidy already mentioned for prenatal care and certain remedial physio- therapy to return persons as rapidly as possible to their normal condition, no other insurance funds are available for this work. 0 5 clerks for physicians; 3 clerks for dentists; 4 clerks for drugs. 104 How the 2% for preventive work will be used has not yet been agreed. An experiment in screening for undetected illness is being sponsored by the Fed- eral Government in Vienna, but has so far not been very successful either in attracting the public or in detecting a very high proportion of the so--called "invisible part of the iceberg". In the Tyrol no initiative has been taken by the insurance schemes, although the AK is actively investigating the possibility of undertaking screening work. As regards management of its own resources, the Tyrol area sickness fund maintains a liquid reserve of no less than 17%. Much of this could be invested to earn a reasonable return. It has already been mentioned that most processing of data is done by hand. The management appears also to be in the hands of legal specialists who seem to be more concerned with keeping the present machinery running rather than looking for ways of becoming more efficient. The insurance scheme also, being nonprofit-making, has little incen• tive to improve itself. It is understood that the other funds in the Tyrol are even less satisfactory. The community public health programme has weaknesses that may well continue until regional planning methods are applied to it. For example, the public health division in the Land is small, so that it is limited in the opera- tions it can pursue. As regards the Amtsarz t , he is generally in the upper age group and concen- trates mainly on his statutory duties. This leaves him with much less time for other activities such as personal health care. The work is full-time and not very well paid, so that there are doubts about filling these jobs in the future. The SAs concentrate mainly on their prosperous general practice and are reluctant to fulfil their public health duties. The job attracts doctors not because of the public salary, which is very low , but because it carries an excellent full-time pension, more favourable than the AK pension scheme. The SM has become a problem because there are now very few domiciliary deliveries. This means that midwives are costing the Land a considerable sum in minimum income guarantees, while the Land is seeing little return in terms of work. Another problem is that many of them are old and o ut of touch with modern ideas on preventive care for mothers and children. MEDIPLAN itself may be looked upon as a useful exercise in preparing for the further development of hospital services on a rational basis, using a number of simple but effective techniques for the purpose. Apart from the stimulus it has given to hospital services, it also plays a useful role in providing a talking• point for government on the one hand - at national and Land level - and for all the remaining interested parties on the other - .-,frz tekammer, university, and the public. It must be remarked that , however good the plan, it was prepared by two architectural con sultan ts with no specialized medical knowledge . Nevertheless, it brings health right into the mainstream of regional planning. The main themes have been developed around re gionalization, the renovation and replacement of hospitals , preventive tasks, and graduated care. Two major criticisms arise at the outset. Firstly, it is a hospital plan ; it takes no account of the overall system of health care delivery by the large num- ber of independent practitioners in the Tyrol. Secondly, it really provides only one option which has not been adequately costed. It should also be observed 105 that, in taking the overall cost of capital investment up to 1990, no attempt has been made to take into account interest and discount rates and the ob- vious implications of price inflation. Furthermore, no detailed estimates of operating costs have been made. In the light of their experience, the consultants could not have been expected to understand the importance of epidemiological change. How- ever, this stands at the forefront of any planning for health services, if for no other reason than that the population in the Tyrol is aging and will in- evitably require more and different kinds of care. Nor, for some reason, has the rapidity of change in medical technology been considered. This is not an easy factor to predict, but changes that already have taken place else- where could have been assessed. In the same way, the failure to take into account the nature and functions of the University Hospital again points to a lack of understanding. In addition to its functions as a university hospital, this hospital serves as the only major hospital for the whole Land. This means that it must perfonn numerous other tasks, including the important function of training the many different para- medical personnel required for the Tyrol. All socioeconomic variables except the demographic changes (including tourism) are left out. Examples of neglected factors include change in incomes with its implied change in demand, change in transport density with the likeli- hood of increasing accidents, and the possibility of change in occupational structure owing to economic development, with the consequent impact on occupational health. While a good deal of thought has been given to the use of hospitals for preventive work and for graduated care, no effort has been made to examine the cost-benefit of the proposals. There is, therefore, no evidence that what is advocated is in fact better than what exists at present. Views expressed locally on the plan include the criticisms that: (a) several interested parties were not consulted, especially the insurance bodies; (b) the independent physicians do not believe that the preventive screen- ing role should be left to hospitals, especially as one hospital has complained that it already has too high an outpatient load; (c) the plan calls for major changes in the size and location of hospitals, as well as in their management and administration , and recommends the aboli- tion of several hospitals , but at the same time takes no account of the fact that the Land has no jurisdiction over the majority of the hospitals ; and (cl) little mention is made of manpower planning ; thus there is a consider- able shortage of nurses , but this is not taken into account in spite of local sug- gestions for upgrading their status and improving their training. Also, the cadre of midwives has become outdated and needs replanning to meet needs. 106 IV FEDERAL REPUBLIC OF GERMANY: SCH LES WIG- HOLSTEIN D.H.S. Griffith 1 & H.F.K. Ziillner2 The Lander of the Federal Republic of Germany may be taken as a further example on a different scale of health service planning and organization com- parable with the Lander of Austria. The State or Land of Schleswig-Holstein was selected for study. It can be regarded as reasonably representative of the federal states in terms of administration and of services. As in Austria , almost all the activity takes place in the Land, so that the place of the Federal Gov- ernment will be only briefly referred to here. The total population of the Federal Republic of Germany was 61.4 mil- lion in 1977. In 1976 the birth rate was 9.8 and the death rate 11.9 per 1000 population. As in the other countries discussed, cancer, cardiovascular diseases, and accidents are the major causes of death. The Federal Government has the power to undertake legislation for the improvement of health and for con- ditions that would endanger public health, to concern itself with admission to different health occupations, to regulate drugs and pharmacies, and to exer- cise control over the environment and food. It also concerns itself with the economic viability of hospitals and the regulation of hospital work. Some of these powers may be exercised at federal level alone, some may be shared be- tween the federal and the Lander governments, and others may be undertaken by a specific Land on its own accord. Generally speaking, therefore, the func- tion of the Federal Ministry for Youth, Family Affairs, and Health is advisory , but it has a major role in preparing framework legislation and is also a col- lector of funds . The Ministry of Labour and Social Affairs is responsible for the operation of all social insurance schemes as well as, to a certain extent , for safety, heal th and welfare at workplaces. Since 1977 this Ministry has been responsible for hospitals , medical technology, fees of physicians and othe r health personnel, and medical rehabilitation . Funds are therefore available for health and allied 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Cope nhagen , Denmark. 2 Health Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 107 services not only from the Ministry for Youth, Family Affairs, and Health but also from other sources, notably the Ministry of Labour and Social Affairs. Schleswig-Holstein is the northernmost Land in the Federal Republic. It has a population of 2 586 800 (1977). In 1976 the birth rate was 9.6 and the death rate 12.4 per 1000 population. The major causes of death are the same as those in the Federal Republic as a whole, namely cardiovascular diseases, cancer, and accidents. REGIONAL PLANNING IN SCHLESWIG-HOLSTEIN Under a federal mandate, all the Lander of the Federal Republic of Germany are required to legislate for the purpose of regional planning. The Schleswig- Holstein law dates from 1971. It lays down the basic principles, objectives, and mechanisms for regional planning, including not only effective land-use planning but also the integration of sectoral plans of ministries, such as those for hospitals and housing. The primary responsibility for such planning lies with the Ministerpriisident (Prime Minister) of the Land. However, a planning bureau is responsible for secretariat services and works under the aegis of the Ministry of the Interior. The secretariat is fust commissioned to prepare a long-term (15-year) perspective plan for the Land as a whole. This plan is designed to provide esti- mates of population changes, population distribution, and likely jobs. It is revised at least every 5 years. Its main objective is to provide guidelines on the major priorities in the development of public infrastructures. In Schleswig- Holstein the Land defined 5 major regions for long-term planning, the basis for the regional grouping being to a large extent population density. The regions fall naturally into zones based around already existing major pop- ulation centres. Long-term plans taking into account the more general direc- tives of an aggregate Land plan are now either completed or under revision for each region. The plans set out priorities for major public infrastructure development programmes and general goals and objectives for county (Kreis) governments and their local communities. It is the duty of all local bodies to comment on them and offer their own alternatives, if any. The comments are considered by the regional planning council for the Land, in which major interest groups are represented and special purpose subcouncils, for example health councils, may be formed whenever necessary. Discussions and clarifications then take place between local and Land bodies until a satisfactory outcome is achieved. With the approval of the Prime Minister , the plan is then published and be- comes binding on the public authorities at all levels within the Land. An innovative concept has been utilized in the long-term infrastructure plans for each region. A number of development centres or nodal points of various levels of importance are defined, the lowest level of which are at least able to provide basic services for a very limited and easily accessible area around them. For example, a rural centre would include the services of a 108 general practitioner, an elementary school, and basic retail and communica- tion facilities. These basic nodal points are functionally related to a number of urban centres, which in turn form a hierarchy of small, medium, and large population centres offering more specialized and complex services according to their size and status. As a result: (I) there are a multitude of nodal points covering the whole of the Land, for which some Land financing must be provided; (2) Land contributions towards the financing and development of pri- ority infrastructure programmes can be allocated on the basis of the im- portance of any one nodal point; (3) by identifying special areas with either development problems or development potential it is possible for federal subsidies to be expeditiously channelled to a large part of the whole Land. At this stage in the process each Kreis drafts medium-term (5-year) plans for the financing and implementation of public infrastructure development projects. All the communities involved participate, and there is a statutory revision of the plans every 2 years. Where communities have a minority opinion regarding their own interests, they can at this time submit it for consideration to the Land. Thus a new round of negotiations between Land, ministries, Kreise, and communities is initiated. The conclusion of the process is agree- ment between all the parties concerned, provided that it is in keeping with long-term priority programming. A very important aspect of this whole pro- cess has been the unanimous acceptance of the relevant law by the whole of the Land Parliament. It is in the context of this regional and Land planning as a whole that planning for health services is developed. Health planning group Health planning is performed by the departmental sections dealing with the relevant subjects rather than by a special planning department or section, but the department of general administration includes a plan- ning officer whose main function is to advise individual departments on planning. Various working groups have been set up on the basis of coopera- tion between the planning officer and the individual departments, and they meet with the Secretary of State as required. They have been largely re- sponsible for developing guidelines, objectives, goals, and priorities in the light of available and potential resources, also taking into consideration political requirements and constraints as well as all other relevant factors. The main problem for them is the continuous strain imposed by their ever- increasing routine workload . Nevertheless, their planning activities have been considerable. 109 PUBLIC HEALTH SERVICES IN SCHLESWIG-HOLSTEIN The public health services in the Land form one department within the Ministry for Social Affairs. Other departments in the Ministry are concerned with general administration; refugees, labour affairs, and social matters; labour safety inspection; and social assistance. All the departments are headed by a secretary who is responsible to the Minister.0 The Department of Health itself consists of 11 sections, all of which come under the control of the chief of the department, who is a physician and full- time civil servant. The sections of the department are as follows: I. General administration 2. Legal affairs 3. Hospital financing 4. Hospital planning 5. Food inspection and control of poisons and dangerous drugs 6. Public health, emergency, and disaster services 7. Licensing and supervision of retail pharmacies 8. Communicable disease control 9. Environmental hygiene 10. Mental health and psychiatric services 11. Health personnel. The Land is, for administrative purposes, divided into counties (Kreise) . In each of these is a Gesundheitsamt or county health office. Heading this office is the Amtsant. He is a physician and a full-time employee of the local auth- ority, but he is under the technical supervision of the Land. He has a deputy and a number of staff who carry out routine public health functions , e.g., sani- tary policing and social work with tuberculosis and with the handicapped. Other functions include: venereal disease and other communicable disease control ; maternal and child health; school health; and statistics. Supervision is exercised over community midwives and nurses. The health office also main- tains a list of all health personnel in the area, both public and private. It is required as well to ensure the hygiene of hospitals and other public and private institutions where the health of the public may be endangered. A model law has recently been drafted for public health functions. It deals with responsibilities at both the Ministry and the county level and defines functions from the Land to the local level. Some of these functions , such as the preparation of health education material for the whole Land, are del- egated to one of the county offices. One other important matter regarding a The Secretary of State in this Land is, exceptionally, a physician. 110 health manpower will be the compulsory census of all health personnel, public and private, each year. This information will automatically be forwarded to the Land. In addition, every health office will be required to be involved in any project or activity with health implications. This is in keeping with the develop- ment of regional planning. With respect to the environment, the requirement is not only to safeguard health but also to promote it positively. All port and air- port authorities will be supervised by public health offices. A major provision in the new law will be that each county health officer should ensure that delegated maternal and child health care and screening activ- ities are in fact being carried out by independent physicians and midwives. These duties entail examinations of infants and preschool children at regular in- tervals; screening of women over 35 years of age for cancer of the breast, uterus, and rectum and of men over 45 for cancer of the rectum and prostate. The work of the midwife in private practice has been steadily diminish- ing; she nevertheless still receives a guaranteed payment from the Land of up to DM 8760 per annum if she does not have enough cases to provide her with a reasonable income. Usually her work now consists of some antenatal and postnatal care. As regards statistics, the county health officers are required to prepare an annual report. Most of the data are in absolute numbers or relate largely to activities done or people seen. Statistical records regarding the activities of in- dependent insurance fund physicians are not compiled by health officers, as this would be the responsibility of the Kasseniirztliche Vereinigung or the sickness insurance funds. In 1976, for example, the top sickness insurance fund organization and the Federal Association of Insurance Fund Physicians (Kasseniirztliche Bundesvereinigung) jointly published a report on the extent to which screening services were made use of and an analysis of clinical find- ings obtained from such screening. Despite the additional or changed programmes and activities, there is no means of measuring cost-effectiveness or cost-benefit in real planning terms. HOSPITAL PLANNING At the end of the Second World War in 1945, Schleswig-Holstein received a sudden influx of refugees, who increased the population by upwards of 40%. Even so, the number of hospital beds was exceedingly high ; there were already 7000 tuberculosis beds and , because of local conditions, it was suggested at the time that they should be increased to 10 000. However, by 1947 it was agreed to reduce the number of beds - which in any case were often inappropriately situated - to 8 per 1000 population. By I 9 56 it was further agreed to reduce the number of acute beds to 5.5 per I 000 population, excluding those in small private hospitals. This is the figure that forms the basis for present planning. By 1957 the construction of hospitals had begun. At that time each county wanted to have its own hospital, but the small counties especially en- countered grave financial difficulties, since each local community was required 111 to contribute two-thirds of investment costs and the Land one-third. It thus became obvious that priorities were necessary and that federal subsidies for construction and other investment would be required. In other words, it was considered necessary to plan the development of future hospital (and other) services. In 1967 a special hospital council was set up within the Land Depart- ment of Health. This was an interdisciplinary team which produced a plan within the next 2 years. The plan was circulated to counties , professional organizations, and other relevant bodies . Subsequent discussions covered not only acute beds but all beds. Finally , by 1973 a plan was agreed on that provides a blueprint for hospital development within the regions. The Depart- ment of Health is at present working on a revision of the plan but, as set out in the plan, hospitals are to be found at central nodal points, in accordance with overall Land planning policy. In evolving criteria for planning, the first factor to be taken into account was that some of the large hospitals were already in situ and therefore the existing situation could not readily be changed except in the long term. On the other hand, because of the need to develop a more efficient and economic hospital service , it was regarded as necessary to close some of the smaller pub- lic hospitals , while at the same time providing the whole population with reasonable access to hospitals. In the case of relatively isolated populations (for example, island communities), a compromise had to be made in terms of both the size and the staff of the hospitals. The principle in relation to the size of an efficient hospital seemed to be that any hospital, to be operationally effective at any given time, required that 3 surgeons should be available. Over 24 hours 9 surgeons would be needed with supporting staff and between 9 and 12 beds each. This amounts to an overall surgical bed requirement of about 110 beds. When similar calculations are made for other specialties represented in basic hospitals, for example medicine, gynaecology and obstetrics, and eye, ear , nose, and throat work, plus a number of beds for specialist training , the minimum number of beds required amounts to about 300 in the specific case of Schleswig-Holstein. In relation to the above estimates it must be borne in mind that a desired target had already been indicated , namely 5.5 acute beds per 1000 population. It should be emphasized that this figure is much below levels in other parts of the Federal Republic of Germany. The figure , however, is for the minimum number of beds; others, e.g., for paediatrics, would be added as necessary according to the same formula. The reason for this relatively low target for beds per population is that, since a sufficient number of independent physicians exist who can provide adequate domiciliary or ambulatory care, a system of graduated patient care is possible and this reduces the need for a large number of acute beds. It is important to note here that the very rapid changes in customs and in technology within recent years were taken into account. For example, most women now expect to be delivered in hospital; among other factors the pill has considerably changed demand for gynaecological and paediatric services ; and more effective home treatment by independent practitioners has reduced the demand for hospital beds. 112 One problem in the development of this hospital plan is the departure of certain specialists , especially surgeons, from the rural areas as the small hos- pitals in which they acted as part-time consultants have gradually been phased out. Another is the large number of patients who require extended care , not necessarily of hospital standard but more than can be given at home . This draws attention to the problem of the need for some kind of intermediate care between home and hospital that exists notwithstanding community (home) nursing care. At the end of 1974 a long-term plan for the construction of nursing homes and nursing departments in old people's residences was accepted by the Land Government. The hospital sector and the non-hospital physician sector still tend to operate as two independent bodies. For example, it appears that diagnos- tic tests are often duplicated, and drugs are given that may mask the diag- nosis after referral to hospital. This points to the need for a continuous trans- missible patient record system (with the development of computers, which is already in hand in Schleswig-Holstein, the task would not seem to be in- superable) . In 1972 a federal law was passed on the financing of hospitals that changed the existing hospital financing scheme radically. Construction costs are now paid by the public authorities, whereas running costs are covered by patients and/or their sickness insurance funds. Approximately a third of investment costs are met by the Federal Government. A special Land law provides that the remaining investment costs should be divided equal- ly between the Land and the Kreise, the latter being entitled to demand a contribution from local administration. The local authorities each con- tribute their third to an investment pool on a population basis in the same way as each Land receives its share from the Federal Government on a pop- ulation basis. Each hospital in the past has had itemized billing for its services. In order to avoid major deficits in hospital operation in the future, the law now requires each hospital to establish daily charges to cover both medical and other opera- tional costs. The Land Department of Health interferes with management of pub- lic hospitals in Schleswig-Holstein as little as possible. It merely allocates funds from the investment pool for the construction of new or the reno- vation of old hospitals. Financing is seen rather as an overall steering mech- anism whereby the Land can persuade the relevant authorities to take action on such matters as bed numbers and location. This is in contrast to some other parts of the Federal Republic , where funds are used to reorganize hos- pital internal management. It should be stressed that guidance on the siting of hospitals is entirely in line with the overall regional planning policy. The average planned investment for hospitals over the next 10 years used to be DM 105 million per year. In 197 5 the funds to be made available by the Federal Government were reduced in view of the financial situation. As a result the amount provided by the Land and the local authorities also decreased and is now - or will be for the next few years - DM 95 million. Out of this, how- ever, about DM 40 million is required to service past debts and deficits , at least for the next 4 years or so. 113 THE ORGANIZATION AND OPERATION OF THE SICKNESS FUND INSURANCE SYSTEM The operation of all sickness insurance in the Federal Republic, except for a few private schemes, is governed by federal law. This law establishes the basic benefits to be provided, including hospitals, doctors, services, and drugs. All individuals below a certain income level who are gainfully employed are required to join. The basic benefits are available in kind and, exceptionally, in cash. Family dependants are also included in the scheme. While there are a number of variations in the different funds with regard to the services offered and payments provided, the example of the Ortskrankenkasse Kiel (Kiel local sickness fund) can be cited as being fairly representative of most of them. The total number of individuals insured through the Ortskrankenkasse Kiel and the 15 other Ortskrankenkassen in the Kreise and major towns of the Land is 680 000. In addition, there are approximately 485 000 family dependants, so that about 45% of the population of Schleswig-Holstein are covered, and about the same number of people are members of other insurance funds. All medical care regarded as necessary by the physician providing services under the funds - whether individual ambulatory care or hospital care - is in principle free of charge to the insured and his dependants. Contributions to the insurance are in general paid equally by employer and employee. Doctors engaging in insurance practice, i.e., virtually all independent physicians outside hospitals, are required to ensure that adequate care is given to any individual who comes for advice and treatment (including care for preg- nancy). The insured have access under this scheme both to general practitioners and to non-hospital specialists. Hospitals do not normally deal with ambulatory patients and, except in cases of emergency, patients in hospitals have all been referred by independent physicians. Referral is to the nearest hospital where the required specialty is available. Necessary inpatient stay is free of charge. If an individual is unlikely to be able to resume his normal duties, sickness insurance is replaced by welfare or disability benefit from another source. Prescribed drugs are given at a normal charge. The physician had com- plete liberty to prescribe any drug, regardless of cost, provided he believed it to be effective , but since July 1977 the total expenditure on drug.5 has been limited to certain total amounts fixed in advance for all physicians. Compen- sation may be claimed from any doctor who is found to prescribe drugs that are too expensive. The main payment in cash to the insured person himself is for sickness absence. This benefit is on a net income basis as soon as the employer's respon- sibility ceases, as a rule after 6 months, and may be paid for I½ years out of every 3 years. Longer periods are paid for by welfare or disability benefits. Another cash benefit is the maternity allowance . In recent years the interpretation of the term "sickness" has tended to be- come more liberal than in the past , and at present it is defined as a condition that would worsen in the future if not treated now. This brings in such services as home nursing care, treatment of alcoholism, and certain aspects of pre- ventive care. Preventive care includes on-demand examinations at periodic 114 intervals of infants and children up to 4 years, screening of women from age 35 onwards for cancer of the pelvic organs and breasts, and screening of men from age 45 onwards for prostatic and rectal cancer. Entry into the primary care system is by Krankenschein (treatment form or chit). In the past a quarterly form was available on demand from the local insurance office, but now the appropriate annual number of chits is mailed to the insured. During each quarter the individual must return for all further care to the same doctor as he chooses initially , except when there is referral or in very specific circumstances. The forms are retained by the doctor, who uses them as the record card for whatever services he renders. The details of treatment are forwarded by the doctor at the end of each quarter to his asso- ciation, and he receives reimbursements from the insurance fund through his association. No cash is paid directly to the doctor by the sickness fund or the patient. Sickness fund offices are in the process of placing all the records on com- puter. The system permits infom1ation retrieved to include not only data on services but personal, epidemiological, and cost data as well. The programme has taken about 10 years to reach its present development. Inpatient data are now being directly fed in by the University Hospital, Kiel , as a further step in data collection. All the area funds are now taking part in this development. The information from the funds on insured persons is on a continuing basis and is more reliable than annual censuses. Fee for service is now the only mechanism for payment for ambulatory care. Before 1969 both fee-for-service and lump sum payments from a common pool to all the independent physicians were the methods used. Payments for hospital services are tending to escalate . Here daily charges are the basis for payment. The hospitals are now required to set these daily charges at levels that cover all their operating costs. Apart from developing information for planning, the sickness fund asso- ciation participates actively in hospital planning. It also participates in working groups, for example in studying such matters as home dialysis. The funds are at present not entirely satisfied with the operation of the health system. They appear to have little influence over any aspect of the de- livery of health care either by physicians or by hospitals. On the other hand , discussions are under way to determine the need for and functions of resident nursing stations and "half-way houses". Nearly all individuals who are not covered by legal insurance funds have voluntarily joined a private fund. In 1977 the number of privately insured per- sons was roughly 300 000. Members of private sickness insurance funds are completely free to choose their doctors. They conclude a contract with them, on the basis of which they are personally responsible for the payment of fees. The share to be covered by his insurance fund depends on the rates previously agreed upon. 115 THE ASSOCIATION OF INSURANCE FUND PHYSICIANS IN THE LAND In the Federal Republic of Germany the independent practitioner does not negotiate for payment directly with either the patient, if he is a member of the sickness insurance funds, or the insurance funds. In order to represent these physicians and to enable them to negotiate fees, an association was formed which is represented not locally but at the level of the Land and of the Federal Republic. The association is called the Kasseniintliche Vereinigung (KV). The duty of the KV is to ensure that adequate ambulatory services are made available to the insured population. lt also has a disciplinary function, that of supervising service quality. lt should not be confused with the Medical Board or .,,fntekammer, which registers and disciplines all physicians regard- less of the work they do. There is a board in each Land as well as a Federal one, but the disciplinary powers are binding for the whole of the Republic. When a licence to practise is revoked, this is done by the Land Ministry for Social Affairs. KV operations are financed by a levy of about 1.2% on all physician reimbursements from insurance. In all there were 4 759 physicians in the Land in I 976. Of these 2331 are in private practice and virtually all of them belong to the KV, because every private or independent physician may become a member of the KV on request, subject only to a number of minor personal qualifications. The number is further subdivided into 1419 general practitioners and I 268 specialists. Of the specialists about 100 are chief physicians in public hospitals, where they have the privilege of charging fees when patients are referred to their particular specialty. Another 130 public doctors, i.e., those working in public health affairs or hospitals, are entitled to insurance payments for screening and early detection work. Since 1960 the physician has had complete freedom to set up practice wherever he wishes. However, with a view to avoiding an unbalanced distribu- tion of medical practices, in I 974 the Ministry of Social Affairs and the KV joint- ly prepared an analysis of the present situation and a forecast offuture develop- ments in medical care, with particular reference to the location of independent physicians. The plan itself proposed I I 8 nodal centres, to which the KV added 80 further centres where physicians should be located to maintain service areas with a radius of 7.5 km each, this being regarded as a reasonable distance for access to primary care, both for the patient and for the physician . At the beginning of 1972 there were nearly 300 locations with doctors, but this has been reduced to about 265. If the 7.5 km limit is accepted, especially in the light of the advent of radio communication between car and practice, the number of locations could be reduced further to about 200. While there is no restriction on where a doctor may set up in practice, there is a very constructive incentive scheme whereby a young physician may be directed to a specific area by a large low-interest loan (DM 150 000) for building up his practice and acquiring equipment, to which is added a 2-year income guarantee. Special financial incentives are also given for the setting up of group practices or altering them. A random look at service statistics 116 suggests that the physicians are a hard-working and conscientious group of practitioners. For example, the statistics show that, on average, all KV doctors expect to see the equivalent of the total popula tion every quarter at least once. The office hours amount , on average, to 35 per week per doctor, and there was a total of 17 .2 million visits, not including over 3 million home visits. If all the services rendered in 1971 are counted - for example injections, advice by telephone, and laboratory work - the KV doctors provided 44 million ser- vices to the population of the Land . The fact that doctors are free to set up in practice wherever they wish to has temporarily resulted in a shortage of medical services in rural areas and in suburban districts . A 1976 federal law compels the KV to prepare plans for areas where there is still a lack of services, and it provides for licenses being temporarily withheld in areas where sufficient medical services are available. The Federal Government expects that physicians who are willing to set up a practice will then settle in areas where there is a lack of services. No restrictive measures have so far been taken , so that no experience of the working of the law is available as yet. For some time now the scrutinizing of the physicians' records of services rendered to their patients has been carried out by electronic data-processing. All records are screened, rechecked for errors, and costed according to items of service and to the tariffs negotiated with the fund associations. Payment is then made to each individual doctor by the insurance fund through the KV. To check for abuses, the computer identifies by simple standard deviation those physicians in each specialty and in general practice who comprise the extreme 4.5% to the right of the normal curve. These records are examined in considerable detail and , if the KV finds that the services provided have been unwarranted , the fees are reduced. The doctor has a right of appeal to a special board where the insurance funds are represented as well and, if unsuccessful, he may have recourse to the law. In the development of this data-processing a number of spin-off benefits are expected to accrue to physicians. For example, the KV may provide in- formation on the literature, the law, and developments in dietetics and toxi- cology. It is hoped that by 1980 data will be available that will have evaluated various diagnostic aids and tests. The data, too, are a valuable input into planning. There seem, however, to be several more or less independent data- processing centres developing, run by different institutions. For example, much of the work done by the insurance agency is similar to, if not identical with , that of the KV. THE PENSION AND RETIREMENT FUND The pension and retirement fund is separate from the sickness insur- ance funds. Nevertheless, it has important activities in the health field in that it deals with tuberculosis and other disabilities that no longer come under sickness insurance. It is thus concerned with certain chronic conditions 117 and with rehabilitation. From July 1978 onwards the services it renders will be available only to a limited group of persons. Tuberculosis is mainly the pulmonary form. Fortunately, with combined drug the rapy, almost all cases today rapidly respond to treatment. There re- mains, however, a hard core of cases in which the lesions are large and chronic and the organism is often resistant to drug therapy. Responsibility for the care of all patients with tuberculosis of any kind lies with this fund, whether it contracts the care out or deals with the cases with its own resources. The fund operates a mobile screening service which is financed by the Land. Experience with tuberculosis shows that it is a diminishing threat to health. Thus , the fund, which also operates in Hamburg, has now ceased to offer screening ser- vices there . It is continuing them in Schleswig-Holstein but is now examining the question whether the services should continue to be offered to the same extent. At present each Kreis is screened approximately once in 2 years. Screening is compulsory for all persons of 18 years and over , but nobody is actually compelled to undergo it. There are no occupations in the Land that are associated with tuberculosis. To carry out active medical and vocational rehabilitation, the fund owns and operates a number of institutions that can deal with about 30% of cases. The rest it contracts out to beds in other hospitals. Last year the number of cases decreased substantially. Owing to the financial difficulties facing pension insurance funds, rehabilitation services are no longer available to the extent they were previously. The fund has carried out a retrospective study of 5 years of rehabilitation activities. The results of this study show that no less than 76% of all cases were able either to maintain or improve their former professional status. It has to be emphasized that among the cases dealt with are a number of paraplegias and chronic renal dialysis cases. Problems that have arisen for the fund are staff shortages, especially at the physician level. In order to avoid setting up its own computer services , it uses those of the area fund in Kiel. Some other joint services have also been set up. While the law has made this fund independent, its relationship with the Land is one of mutual assistance. It has been involved in the Land planning council and participated actively in the preparation of the Land hospital plan. AN APPROACH TO A LAND INFORMATION SYSTEM The Datenzentrale (Data Centre) provides or will provide computer ser- vices on request to public authorities within the Land. Its immediate ap- plication in the Land health services has been to payrolls. An important implica- tion for health services is the work it does on the registration of all persons settling in the Land, who must give notice to the authorities; the data centre keeps a record of them. A bill by the Federal Government to give each in- dividual a single identifying number was not passed in Parliament because 118 it was considered to interfere substantially with personal freedom. If it were passed , record linkage in health services could be achieved and readily become a useful tool in planning and evaluation. The main stimulus, however , to the creation of a health information system comes from the federal law on hospital financing, which requires each hospital to develop a book-keeping and cost-accounting system as in industry. About 30 hospitals have joined in an integrated data-processing system, which is run by the Data Centre on behalf of the authorities respon- sible for the hospitals and is at present chiefly used for invoicing and service accounting. It is proposed later to add medical, epidemiological, and inven- tory accounting, but this will have to be developed by the joint action of all or several Lander. The goal is a system that analyses the hospitals from different angles - from that of the patient, e.g., the waiting time; from that of the staff, e .g., less routine work; from that of the hospital authority, e.g., bed occupancy; from that of the health planner, e.g., detailed epidemiologi- cal forecasting; and from that of the overall economy, e.g., optimal hospital size. In addition, the health services in general, on the basis of the residents' registration system, can call up specific age groups for screening, for physi- cal examination, or for immunization. Participation in this scheme is at the moment purely voluntary, but the use of modern management techniques and the subsequent improve- ment in services will inevitably bring in the more traditional and less effi- cient health service managers and administrators so as to obtain similar bene- fits. But this by no means exhausts all the possibilities. The staff appear to be capable of carrying out simulation studies of different components of and interrelations within the health service system. COORDINATION OF PLANS One official in the Ministry of Social Affairs has special planning duties. He is also one of the senior officials who, together with the Secretary of State, form a multidisciplinary and informal ad hoc planning group with changing combina- tions of physicians, administrators , economists, lawyers, and statistical workers. The planning official is one of the general administrative staff of the Ministry and is an economist. His duties within the Ministry are to advise all officials on technical planning matters. As well as this he has the function of liaison and coordination with all groups in the Ministry and he has developed a system of exchanges between different departments and units. With this system it has been possible to lay down a common planning method, the general principles of which are similar to those used by others in planning. Three types of interrelated plans can be distinguished. The first is the long- term plan to meet desired goals, objectives, and targets within 15 years or so. The second is a medium-term plan that includes some programme planning and budgeting and covers a period of 4-8 years (average 5 years). The third is a detailed annual implementation plan, including network analysis. 119 Planning in each ministry was decided on in 1971 by the Government. However , only the social and the economics ministries so far have full-time officials engaged in the work. Nevertheless, all the ministries have a joint monthly meeting of those responsible for planning to coordinate overall planning. The mechanism for planning is maintained by scheduling important projects on special forms. These are circulated to all the relevant departments regularly with a description of the present status of the project. This keeps all officials aware of their own part and that of others in the development of the project. This is an important monitoring function. Among other effects this mechanism enables officials to forecast legislative changes and costs. It will also give an opportunity to the coordinator to assess the extent to which depart- ments implement official policy; so far it has not done so since implementation is the responsibility of individual departments. Before actual plans are passed to the authorizing authority (the Coun- cil of Ministers of the Land), a final review is made in a meeting of the Sec- retary of State and the officials responsible for planning in each ministry to ensu re that the regional, departmental, financial, and political elements are in balance. The whole mechanism is in fact a systematic and rational implementation of the ministerial policy stated at the beg.inning of a legis- lative period. EMERGENCY SERVICES IN THE LAND The hazards of everyday life , especially traffic accidents, are increasing rapidly. Tourists who venture out to sea may suddenly require assistance. In addition, the stress of modern Jiving has caused an increase in sudden deaths from coronary infarction. It appears that about 50% of people dying in traffic accidents have died on the spot, largely owing to the lack of adequate and timely attention. The cost of traffic fatalities is said to be 1200 times higher than the cost of light traffic injuries and about 40 times that of serious traf- fic injuries. The average length of stay of a serious accident case, too, is not less than 7 weeks. Because of this alarming situation and because of the in- crease in cardiac and circulatory disease, it was felt necessary to plan for more effective emergency services. Planning is based on a rescue and emergency service law passed by the Land Parliament in I 975. The law specifies the bodies responsible for such services and their organization, staff, and equipment. One of the provisions is that no hospital should be more than 30 km from any community. This means that the responsible coordinating agency is the Kreis, where ambulance, fire brigade, and rescue services are readily available. The law provides that all activities within every Kreis should be coordinated by an emergency control centre (Rettungs/eitstelle) . Another major component is the communication network. It is possible to telephone directly free of charge to a number that will put the caller in touch with the emergency control centre, and telephones have been placed at intervals along the major highways. 120 The ambulances have been modernized and given improved equipment, for example a connexion providing the hospital physician with an ECG reading and a cardiac defibrillator for use if necessary. Instructions can be given by radio from the hospital physician involved. In addition , a number of physicians are on call for emergency care. A federal bill on the training of ambulancemen has been drafted but has not been passed so far. In Schleswig-Holstein ambulance- men are required to complete at least 500 hours of training, to enable them to handle seriously injured and unconscious patients. For outlyin.g areas and coastal waters - and in emergency in other areas too - the defence forces provide aircraft, helicopters, and special boats. In addition, helicopters owned by private rescue organizations are stationed in two central towns. In any particular case it is the responsibility of the emer- gency control centre to decide whether a helicopter should be called or not. The cost of transportation is paid by sickness insurance funds. In this con- nexion, the need for providing suitable landing areas was taken into account in the hospital plans. Local emergency medical services and independent practitioners Local emergency medical services are often private organizations run by a number of local medical practitioners. The main object is to enable patients to obtain rapid medical assistance either from their own or from a number of doctors on call. The system operates outside normal working hours . On receipt of a call the centre controller informs the first doctor on call of the request. (If necessary, he first calls the emergency radio service run by the fire brigade, which then contacts one of the physicians, each of whom has a radiotele- phone in his car.) Should the first doctor on call be already engaged, the second is then contacted. In all , some eight doctors can be on call consecu- tively in an order that is changed daily. Some practitioners, whether on call or not, prefer to be informed first when one of their own patients is involved, and only if they are unavailable is the doctor on call contacted. Since he has a radiotelephone in the car, the doctor who has gone to the patient is able to call for an ambulance or other assistance as necessary. An independent practice office or consulting-room is likely to consist of a waiting-room , a reception room, a laboratory room, and two offices adjacent to one another. The equipment carried by the practitioner, besides the usual examination couches, weight scales, and the like, also includes two ECG machines, heat and short-wave therapy apparatus , and a variety of laboratory material including a photometer, a microscope , and similar quite sophisticated apparatus, all of which are used. The physician is assisted by another physician . Work begins at 7.30 a.m. to deal with patients who call in before going to work. Later there are special appointments, for example for the taking of blood specimens, which will be examined and reported on later in the day. Work goes on until approximately 12.30 p.m. House calls are made from approximately 2.00 p.m. to 4 .00 p.m. by car. Patients again attend from approximately 6.00 to 8.00 p.m. or even later. During weekends also, although there are no office hours, the practice sees any caller if the doctor is available. Coverage is required any time the practitioner 121 is not present and is usually ensured through the emergency service. To assist in dealing with patients there is a staff of 2 or 3 receptionists who work in shifts. In addition, a laboratory technician comes for 3 days each week. On arrival the patient enters the waiting-room. In some surgeries he draws a numbered ticket and when the number comes up on an indicator, he goes to the receptionist's room. Here he presents the sickness treatment form if this is his first visit for the quarter, or he identifies himself through the doctor's record system. The appropriate details are retrieved and the patient then waits again until the physician is fre e. He is then given the services believed necessary, each service being noted for submission to the doctors' association at the end of each quarter. About 1 % of the reimbursements are paid to the doctors' insurance association and another DM 700 monthly for private sickness and pension insurance. The doctors have no fixed retirement age. About 1200 patients are seen every quarter. The total number does not change much and the patients are mostly of long standing rather than indi- viduals "shopping around". The system works quite well; the patients are satis- fied, and so are the colleagues of the doctors. PREVENTIVE SERVICES Most elements of the tuberculosis programme have been dealt with above (page I 18) . Tuberculin testing is recommended for children between 12 and 18 years and there is an acceptance rate of about 90%. An important new element is the annual and subsequent biannual check of foreign workers for tuberculosis . A pre-employment examination is required by law for all workers in factories and other industries younger than 18 years. This indicates their fitness for various kinds of work. Periodic checks are made of major risk groups. Safety on the job and occupational hazards are largely taken care of through the Ministry of Social Affairs, which exercises supervision over the craft and industrial workers' occupational accident insurance funds. Each particular industrial and craft fund drafts safety and health regulations for its own group of workers, the drafters being specially qualified in the in- dustry concerned. A new federal law requires each firn1 or plant to provide occupation- al medical and health services on at least a part-time basis. The physicians employed will be actively involved not only in existing occupational health work but also in giving advice on the introduction of new processes and technologies. The responsibility for school health lies with the Kreis public health authorit ies. A shortage of doctors has created difficulties in carrying out exam- inations and follow ups of schoolchildren. Much of the work is carried out on a part-time basis, usually by independent practitioners. The initial examina- tion determines the fitness of the child for admission to elementary school. Children with various problems throughout their school life are referred to this 122 service. Booster vaccinations are also offered through the public health auth- orities. One of the most important is the recen tly begun rubella vaccination of 10- 14 year-old girls. With respect to physical education , teachers are given special courses in gymnastics and medical gymnastics. Special courses on drug addiction are also offered to teachers, and thought is now being given to introduc- ing these subjects into the general teacher-training curriculum. Another element in the schools' programme is the issue of fluoride tablets. Pre- ventive dental treatment is difficult to provide because of the shortage of staff. Maternal and child health care (MCH) services were largely provided by the public health authorities of the Kreis. With the recent change in the insurance law, however, most MCH work has passed to the independent insur- ance practitioners. The law calls for the examination of pregnant women up to 10 times during pregnancy. For the newborn and for children up to 4 years of age examinations can be requested by the parents 7 times. These examinations are all paid for by the sickness funds. To date abou t 40-60% of people have been found to make use of these services. It is still too early to evaluate the performance of this work. To promote screening for mothers and children, the Land now provides special booklets informing mothers about the health of their children. Screen- ing of women over 35 years of age and of men over 45 years is also provided for in the new law for cancer of the breast and pelvis in women and for cancer of the prostate and rectum in men. This service is on request. Other screening is for diabetes and for circulatory disorders. Health education has been given a prominent role in prevention and screening. Promotion of health is carried out through all the media ; exist- ing institutes are given subsidies; literature is provided ; exhibitions are organized ; adult education is encouraged; and a special telephone service giving health information on various matters, including venereal disease and family planning, has so far been used by some 4000- 10 000 callers per month. The Land has introduced 8 full-time dietary advisers with dem- onstration kitchens at office hours within public health offices. It is now planned to give regular dietetic advice to persons discharged from hos- pitals. The Land plans and finances most of these and other activities except health insurance through a large number of semi-private institutions and as- sociations on a Land or Kreis level. The Land is always represented on the boards of these groups and provides them with funds as well as with operation guidelines. The actual implementation of the programmes is by the associations themselves. The first advantage of this appears to be that broad consumer groups are represented, the second that they can obtain additional funds through charity and voluntary contributions. While this method of enlisting the community in health endeavours appears meritorious, it is nevertheless difficult to measure the impact and efficiency of the programmes and of the use of public funds. 123 SOCIAL INr:RASTR UCTURE PLANNING At the peripheral level one of the main links with the population is the commun ity nurse. She is provided with a house, a telephone, and a car (or mileage allowance). More of these nurses are found in the north-west, where doctors are less numerous. Although her functions are mainly curative, the community nurse acts also as a guide and counselJor to families. In addition, she puts families in touch with other health workers. She is sometimes em- ployed by communities, some times by private charitable or church groups. TechnicalJy she is supervised by the Amtsarzt. The actual distribution ratio of these nurses is 1 : 2400 population in the north and I : 9000 in the south close to Hamburg. Another worker who is being utilized especialJy for domestic assistance , e.g., when the mother is in hospital, is the home help. She is not trained in health matters but does such work as housekeeping, budgeting, and cooking. She too is employed by communities or local bodies. There are two other types of social worker. The first is workers attached to health offices, each office having one or two. Their work is entirely confined to rehabilitation and supervision of the mentally and physically handicapped and drug addicts. The second type is found in community social welfare of- fices. They are concerned with other social problems of various population groups and also determine the need for cash assistance. Each one of these workers covers about 8000-10 000 population. In and around this more structured framework are a multiplicity of chari- table and church bodies. Any one of these official and unofficial groups can, and does , act as a local clearing-house for others . The official social welfare workers have recently tended to become more specialized in individual problems, e.g., adolescents or kindergartens. In conse- quence they are playing a much narrower role in basic community work. From this it would seem that the organization of primary care and referral is due for a restructuring. In order to improve the present situation the social services de- partment has prepared a number of plans and programmes. Social service centres o r stations for old and sick people o r for people who need help for other reasons are being tried out at present. Depending on the location of such centres, either in chiefly rural o r in urban areas, they will cover IO 000-30 000 in- habitants . One of the objects of these trials is to find out the optimum size for such centres. Each centre would at first act as a nuclear point for social and health workers ; thus they would be expected to have 3- 4 community nurses and home helps in a group . As the centres develop , it is anticipated that ser- vices could be established for old people , rendering assistance with laundry, feeding, recreation , and information. A major difficulty was estimating the extent of the problem of the hand- icapped . This was overcome by bringing together various experts and prac- titioners, whose "educated guesses" have so far proved to be reasonably sound. Plans have been made for special kindergartens, schools, sheltered workshops, and residential accommodation for the men tally and physically handicapped. 124 Another plan has been prepared for geriatric nursing homes, where the de- sired ratio of beds to the population aged 65 years and over will be 25 per I 000 in urban areas and 20 per I 000 in rural areas. Requests for assistance in providing these facilities come from the local communities and are coordinated by the Land . The main guiding mechanism is the financial subsidies provided by the Land . One major problem is the un- planned activity of the various private organizations; unremitting efforts are required to obtain a consensus between all the private and public concerns. The results are nevertheless considered satisfying in general. It is unlikely that deficiencies in this sector place burdens on the health sector, but the data have ye t to be analysed. HEALTH MANPOWER AND COMPAR ISONS WITH THE fEDERAL REPUBLIC The main health professions, besides physicians, den tis ts, and phanna- cists, comprise nurses of varying kinds, occupational and physical therapists, masseurs, remedial gymnasts, balneological therapists, social workers, tech- nical assistants, health inspectors , and a number of aides assisting the various professions. In addition, various chiropractors, herbalists, homoeopaths, and the like are licensed to practise by the Land, provided that they do not handle matters of a grave or life-endangering nature. A new profession is that of sanitary engineer. Discussion is also going on about the training of dental hygienists who will - unlike present dental aides - carry out actual work in the mouth. With regard to numbers, Schleswig-Holstein in the past had not such a high ratio of skilled to unskilled services as the Republic as a whole. Now it is in the same position as the Republic , mainly because of the increase in licensed practical nurses . Furthermore, the number of places available for nursing training is better in Schleswig-Holstein; in effect , it can fill all its nursing needs with little difficulty and without foreign nurses. A further source of supply is the part-time nurse. Here also it has an advantage over the Republic as a whole . In round figures there are over 4000 physicians in Schleswig-Holstein, of whom about half are in independent practice. There are only about 140- 150 foreign doctors, who work mostly in the less well served specialties, e.g., surgery, obstetrics, and anaesthetics. A number of interesting rulings about physicians have recently been made by the High Court. The independent physician has a duty to make complete services available all round the clock , whether in specialist work or not. This means that not only must general practitioners be available but that specialists in all disciplines must also provide an adequate service in each of their special- ties ove r 24 hours ; or, alternatively, they must satisfy the Arz tkammer that they can also undertake general emergency work regardless of their discipline . This ruling stresses the principle that an independent doctor is always a general 125 physician first and a specialist only later. It further implies that all physicians, and in particular specialists, may well have to undergo regular refresher and retraining courses. Discussion is going on about the question whether in all these groups suitable multiple specialties can be taken up and practised in so far as they are compatible . This has been difficult in the past. Finally, to provide incentives and improve the status of those branches of the medical profession, university chairs are being created in general practice and in public health. Furthermore, a number of places in medical schools will be reserved for students who agree to specialize later in public health. The same students will receive tuition free, provided that they enter into a bond to serve for 12 years. It is possible that the same conditions may be offered in the future for general practice. PSYCHIATRY AND ITS POSITION IN THE LAND The psychiatric hospital at Neustad t consists of old and new buildings, situated in a traditionally well-spaced environment. It has the following de- partments: Male psychiatry Female psychiatry Geriatric psychiatry Forensic psychiatry Drug dependence and alcoholism Rehabilitation Neurology 335 patients 195 patients 145 female patients 185 male patients 142 patients 93 female patients 50 patients The occupancy rate was very high, but decreased from 99.6% in 1971 to 82.9% in 1976. The average length of stay for 52.3% of patients was less than 3 months, but for 25.7% was less than 3 weeks. In this Land a number of criminals found guilty but insane and others admitted for an expert opinion on criminal respon- sibility cause the length of stay to be abnormally prolonged . Admissions are for a number of causes. For example, in 1976, 5 5.1 % were for alcoholism and drug dependence (the latter 4.5%). Schizophrenia and manic depressive illness accounted for 16.7% of all admissions (12.5% and 4.2% respectively). Geriatric neuropsychoses accounted for another 13.5% approxi- mately, while the remaining admissions were for general neuroses, oligophrenia, and psychopathies . The picture looks different if one looks at the patient popula- tion , because of the differing lengths of stay after admission. Schizophrenia in 1975 accounted for 37.2%, oligophrenia for 26%, alcoholism and drug ad- diction for about 13.5%. The situation , however, for alcoholism and schizo- phrenia is not well reflected in this , because many of these cases are multiple readmissions. It was believed that much of the latter problem is attributable to the lack of adequate social follow-up care in the community . This appears to be true not only for the young but for the old also. 126 Another problem faced not only by the hospital in Neustadt but by the Land in general was the influx of geriatric patients originally from Ham- burg (a separate Land) who had migrated to communal old people's homes in Schleswig-Holstein. These problems were aggravated by difficulties in obtaining both physicians and an adequate budget. Physicians wishing to specialize in psychiatry are not attracted to a hos- pital like Neustadt ; the income is better in university clinics because of the bet- ter opportunities for casual or additional earnings, and Land hospitals like this are usually in small towns which are professionally unattractive. Other per- sonnel, however, particularly nursing personnel, are easier to obtain. There is little competition from industry here and the hospital has housing available and exce llent personnel management. Funds for departments for acute cases are provided by virtue of the federal hospital financing law mentioned above. An approximately equal amount is made available by the Land under its own hospital reconstruction programme. These funds are also used to improve the departments for chronic patients and individ- uals requiring constant nursing care. Under this programme the Land has done a great deal in renovating old buildings as well as in putting up new buildings. The distinction between acute patients and those requiring constant nurs- ing care is also of decisive importance with regard to the operating budget. Sickness insurance funds take responsibility for acute patients only , since in their opinion only acute cases require hospital treatment. The cost of hos- pital treatment for other patients is paid by the Land. Apart from reconstruction of a sound and simple nature, a number of occupational therapy and rehabilitation activities have been introduced for about 63% of the occupants of psychiatric hospitals. They include small in- dustry , handicrafts, electronics, gardening, and the manufacture of objects for sale . The proceeds from sales are used as direct cash rewards to patients and to pay for several leisure-time activities. The Land has had to accept the fact that major psychiatric services are historically based on the eastern and northern parts . Because of the existence of these centres it has been considered to be uneconomic to demolish them. At the same time, the health plan requires that a more rational approach should be taken to the siting of new psychiatric beds. One principle on which the new plan is based is that of dece ntralization closer to the residences of pa- tients. This requires that some 300-400 beds should be added by 1985 in the southern and western regions. The second principle is that general hospitals should have psychiatric beds. Thus the general hospitals at Itzehoe and Neu- miins ter have psychiatric wards, and general hospitals in Elmshorn and Kiel will also have psychiatric beds. It would appear that certain conditions are straining the resources of the existing psychiatric hospitals. These are mainly alcoholism, geriatric conditions, and schizophrenia. As a support and as an economic measure , day and night clinics and half-way houses near sheltered workplaces are considered to be more suitable for some of these patients. For others special homes providing mainly nursing and domestic care are being planned. Less thought, however, appears to have been given to community home nursing and to social welfare services that reach the communities themselves. 127 Psychiatric services for childre n and young people have in the past been concentrated in the same regions. The future requirement fo r the plan is 2 new 25 -bed children's departments in general hospitals at Elmshorn and Lubeck. There remain the problems of the oligophrenias and criminal wards within the Land's psychiatric hospitals. According to present policy oligophrenic patients should live either at home or in sheltered homes where those who can work should be given the opportunity to do so. The remaining patients will still be cared for in the psychiatric hospitals . Special institutions, al- though they have some advantages, have also seve re disadvantages. For the criminally insane the conditions appear to be such as would not encourage any social rehabilitation at all. New buildings already in the planning stage will improve rehabilitation work. ENVIRONMENTAL HEALTH PROTECTION Nearly every Land ministry has responsibilities in relation to the protec- tion of the environment. The Ministry of Agriculture deals with water, wastes , and landscaping; the Ministry of Economics with the location of industry; the Ministry of the Interior with regional planning; and the Ministry of Social Affairs with environmental health, dangerous emissions, etc. A secretariat for environmental protection has therefore been set up by the Land Prime Minister and placed administratively within the Ministry of Social Affairs. The task of the secretariat is to coordinate the work of the various ministries in environ- mental matters as well as in federal matters affecting the Land. An interminis- terial council meets every month and an expert committee for environmental protection consisting of scientists and others assists the secretariat. Construction permits and subsidies by the Land are utilized to guide the development of the infrastructure in line with environmental priorities. Plans already established for a water supply system and for solid and fluid wastes are based on the general regional planning guidelines and utilize the same planning mechanism. Only a few counties and local authorities have institutions similar to those of the Land , but they are being developed de facto because of the requirements of county development plans. The impetus for environmental protection plan- ning comes not only from the authorities but also from many private initiatives and pressure groups as well as from the requirements of tourism. The responsibility for environmental health services lies with a special department of the Land Ministry of Social Affairs. Up to now the main activi- ties have been in relation to water quality, air and noise pollution, and the pub- lic health evaluation of infrastructure projects under consideration. These tasks are delegated to the county public health offices and labour safety inspection offices, which will in turn be supervised by the Land. The county offices suffer from a great shortage of qualified staff. The Land has therefore taken the initiative by training 20 engineering graduates for I year for public health service. Of them 15 have already been placed in 128 county public health offices. It should be noted that the t raining is not narrow- ly tailored to traditional sanitary engineering but includes all the relevant public health tasks. In formation on environmental health risks is now collected by each county public health office in widely differing and incomplete ways. An in- stitute of environmental toxicology has therefore been set up to provide the relevant information and monitoring on a Landwide basis . Its attempts to develop environmental health risk indicators of the total environmental burden on representative population groups will be of interest. PHARMACIES , PHARMACEUTICAL SUPPLIES, AND PHARMACEUTICAL CONTROL Any qualified pharmacist can set up a pharmacy where he chooses. The pharmacy has to meet certain legal requirements , including the provision of equipment for testing the quality of basic materials. At present most pharma- cists prepare only a minor amount of the various pharmaceuticals ; instead they purchase either from wholesalers or from industry direct. The hospital phar- macies tend to make more of their own preparations. No pharmacist may own more than one pharmacy (unless he has a pharma- cist wife who also owns one). He is subject to the control of the Land auth- orities, which means that he is subject to inspection in relation to the state of his premises, the keeping of certain preparations laid down by law, and the arrangements for night opening. The inspectors are designated by the Land from among the pharmacists themselves. In Schleswig-Holstein there are five , their inspection areas being outside their own region . There were 531 pharmacies at the end of 1977, and 17 in hospitals. There is roughly I pharmacy for 4850 inhabitants in the Land. Most of the work of the pharmacies is dispensing the drugs prescribed by independent practitioners belonging to the sickness insurance funds . The trans- action is virtually free for the patient, only a nominal sum being charged. Pre- scriptions are kept and submitted each quarter to an agency that examines the details and prepares the bills . These are then checked and paid by the sickness funds . All registered physicians have the right to prescribe whatever drug or drugs they believe patients should have. They have no right to dispense drugs. The pharmacist, without the agreement of the physician, cannot substitute for a drug a similar but different brand. There is no national formulary as in other countries. This means that drugs are stocked under their names. In consequence the pharmacist is required to carry a large stock in order to satisfy the needs of all the practitioners and their patients. In all , there are about 60 000 preparations. To overcome the problem of carrying the whole range, some pharmacists , along with local wholesalers and retailers, are automating their ordering and inventorying. Thus, a microfilm is supplied at a low rental together with the appropriate reading device . It lists all the drugs, their cost, the registered number , the recommended price 129 to be charged, and any changes since previous issues. The film is supplied each month and makes stocking easy for the pharmacist. The stock itself can be held in numbered or lettered boxes. Each stock con- tainer has a small computer card attached , with the number of the drug, the opti- mal amount to be held, and the minimal number to be lef t before reordering. On the minimal number being reached the card is removed and placed in an on- line computer channel along with other reorders . The drug is then automatically called for from the nearest wholesaler. The drugs required can be received to- gether with the invoices - also automatically processed - on the same or the fol- lowing day. This particular system has saved I pharmacist from carrying 40 000 preparations, his stock now being some 15 000 instead of a possible 60 000. It has also reduced staff requirements by about 15. The system is being used and adopted by other pharmacists, but often with less sophistication. Cost control of drugs was almost nonexistent , but since I July 1977 a federal law has been in force, the object of which is to reduce the cost of health care. This law iays down that the federal associations of sickness in- surance funds and the federal association of sickness insurance fund physicians should agree on a maximum amount to be spent on drugs . If this maximum is exceeded insurance funds require overprescribing doctors to reimburse the ex- cess unless they are able to furnish proof of the necessity for prescribing such expensive drugs. Apart from this check on overprescribing, a physician can pre- scribe any drug - cheap or expensive . It is noticeable, particularly when new drugs or brands are drawn to the attention of physicians, that almost at once other similar drugs are discarded in favour of the newer more expensive ones. The only control appears to be through market competition . . There has been discussion on centralized bulk buying of drugs for public hospitals, but this is not likely to take place in the near future. A more powerful system exists for quality control. This was established _ by a federal law of 1961 for medical and veterinary preparations. Since 1 Jan- uary 1978 a new federal law has been in force by which the quality standards required for drugs have been further increased. In addition, a responsible per- son with specialized training is required to be in charge of the preparation of such drugs. COMMENTS It is quite clear that in Schleswig-Holstein a dynamic and systematic planning process is in operation, working through the political and socio- economic system. The basis for regional planning in general is the identifica- tion of major regions and, within these, nodal points of differing size, capacity, and importance. A number of sectoral plans have been dovetailed together, including plans for most sectors and subsectors on both the economic and the social side. One of these plans is for health and another for social services, subsectoral plans comprising hospital , primary medical care, and other health and social services. 130 Two useful mechanisms fo r planning have been developed in the Ministry of Social Affairs. The first is a planning group, the second the appointment of an official who has been made responsible for planning and for the coordina- ti on of all planning activities within the Ministry . All the officials and outside agencies interviewed appeared to be well aware of the planning process, its potential , and the problems involved in developing and implementing plans in a pluralist society where numerous public and private agencies deliver services. The impetus to planning comes from many sources. Consumers and private organizations form pressure groups. Professions in the health field look to the interest of both their patients and themselves. Administrators look for a system that is rational and effective . Politicians have a duty to provide efficient ser- vices. A further impetus is given by federal and Land legislation and by High Court decisions on matters of principle. Planning in its present form is relatively recent. This implies that planning machinery, staff, and information have not yet fully realized their potential. It may be noted that these planning principles exist on a Land basis. They differ of course in detail from Land to Land. However , Schleswig-Holstein, although one of the poorest Lander, does not appear to be at a disadvantage in its health services as compared with the national average , nor is its health status relatively worse. There are nevertheless some areas in the health sector where improvements would seem to be feasible . A major area where improvement could be achieved is in the field of information . Several independent computer systems are in operation without any clear linkage between them. Moreover, much of the infonnation available in each of the systems does not appear to have been analysed entirely satisfactorily. Of the different developments planned few are evaluated by a pre-investment analysis that would indicate the likely benefits in terms of reduced health risks and problems or the likely economic burden on different population groups. The planning group of the Ministry of Social Affairs is fully aware of these problems and is engaged in the task of working out solutions. Another area that does not appear to have been given enough stress is the forecasting of epidemiological and inflationary trends. Some additional attention should also be given to further analysing each health subsector in terms of a total health plan . Many of the above points would seem to indicate a need for simulating and evaluating alternative approaches to health service delivery before em- barking on a final planned programme. Simulations are also useful for moni- toring crucial steps in plan implementation. These comments carry the following implications. ( I) Information is needed that can be pooled from already existing sources in a comprehensive way and be subsequently analysed along the lines mentioned above . (2) Senior staff are needed who are knowledgeable in health service de- livery and can at the same time work comfortably with systems analysts. It needs to be stressed here that many of the present staff have this capability, but they are so occupied with routine but essential administrative work that 131 their time for other activities is relatively little . The question of a special group freed from routine work should be considered. (3) Groups of "in-house" consultants are needed who can bring their expertise to the above senior staff on appropriate forecasting, simulating, programming, and evaluation tasks. Another area that would seem to require considerable upgrading is that of the basic social services , not only for themselves but also because of their con- tribution to the health of the population. If the burden on hospitals is to be re- duced in line with the hospital plan, taking the aging population into account, social services would appear to require more efficient planning and more coordination with the health sector. The Mjnistry of Social Affairs is confident that a satisfactory solution will be brought about by social services planning measures that will accompany hospital planning. One matter of considerable importance for planning is a clear under- standing of what planning is all about and why it is done. At present neither the physician , nor his patient , nor the hospital doctor generally has any idea at all of the cost of a series of visits or of a stay in hospital. As consumers or providers of services, all of these individuals expect to be given or to provide the best. On the other hand , as taxpayers they complain of the ever-increasing costs of care. Therefore, if for no other reason, planning still needs to be developed to deal with these conflicts and to involve everybody in what is being done, how it is being done, and how much it costs. The use of the present population as the key for the allocation of invest- ment funds on a Land and Kreis basis does not appear to be the most satis- factory way of estimating future inpatient needs. The federal law does not apply to custodial and chronic beds. Therefore some hospitals, especially those providing subacute and chronic beds, are at a disadvantage as compared with acute hospitals. This may lead to a further deterioration in chronic hospitals and facil ities. Because of the time between the introduction of the bill and its passing, some authorities delayed their plans until they were assured of additional funds. In consequence , there has been a flood of investment requests, all of which take time to handle. As a result , inevitable delays in construction have occurred. One irnportan t and constructive requirement has been the annual detailing of all construction scheduled for the coming fiscal year. In effect, this amounts to an annual pre-investment screening, which is essential for planning. 132 V HUNGARY D.H.S. Griffith 1 & H.F.K. Ziillner2 The ultimate authority in the Hungarian State at national level is Parlia- ment. The principal executive body, the Council of Ministers , one of whose members is the Minister of Health, is appointed by Parliament. At subnational level the country is divided into 19 county councils, plus the capital city of Budapest. Each of these divisions has its own executive committee. A depart- ment of health is responsible to each executive committee for health matters . Large towns have a municipal council with arrangements similar to those in the counties. At the lowest level are to be found rural councils, also admin- istered by executive committees. They are advised on health matters by the local district officer (Fig. 1 ). Hungary lies in central Europe, bounded by Czechoslovakia on the north, Romania and the USSR on the east, Yugoslavia on the south, and Austria on the west. The population was about 10 300 000 in 1972, Budapest, the capi- tal, accounting for some 2 000 000. The birth rate was 14. 7 and the death rate 11 .4 per 1000 population. Common causes of death are cardiovascular disease, cancer, and accidents. HEALTH PLANNING AT THE NATIONAL LEVEL The integration of health and economic planning Until recently both short-term and long-term health planning within the Ministry of Health were combined in one department, Department 6. While Department 6 continues to be responsible for short-term planning and for the 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Copenhagen, Denmark. 2 Health Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark . 133 Fig. 1. Organization of the State in Hungary Bodies of State authority PARLIAMENT Presidential Council County/Capital/ Council Municipal Council Rural Council C -= committees S • secretariats I = institutes and institutions Executive bodies of State (appointed) Council of Ministers Executive Committee of County/ Capital /Counci I Executive Committee of Municipal Council Executive Committee Special authorities of State Ministry of Health Department of Health Department of Health General practitioners/ district physicians operational aspects of plan implementation, a new department, Department 13, has recently been created to deal with long-term health planning. The two departments work in close cooperation with the National Planning Office. The key agency for economic planning is the National Planning Office (NPO). It has a department mainly concerned with health, more particularly with the planning and coordination of health services. There is close collabora- tion between the planning groups in the Ministry of Health and the health department of the NPO. Before any plan is prepared, the NPO passes on to the Ministry overall data regarding national investment, consumption, population 134 forecasts, and other macroeconomic variables. At the same time the planning groups in the Ministry prepare their own particular data, with more emphasis on detailed participation for health programmes. The outcome of the ensuing negotiations is the allocation of a proportion of the national resources and funds to the health sector, together with certain guiding principles for the employment of such funds. Since 1950 the recurrent national health budget has increased its share of the government budget from 2.3% to 3.5%, and there is likely to be a further slight increase in the future . Funds for new capital investment amount to 1.2%-1 .5% of the national investment budget. In addition, institutions are given a further annual sum for major reconstruction and maintenance equivalent to 1.2% of the value of buildings and 3% of the value of machinery . Henceforth more attention is to be paid to the regular annual maintenance of buildings and machinery to avoid major critical breakdowns. One obstacle to achieving this goal is the tendency of local authorities at times to favour one particular institution at the expense of others. The planning of health and other social services is undergoing a change. Hitherto health services were mainly justified from a humanitarian point of view, as belonging to the general standard of living of the population. Now ef- forts are also beginning to be made to justify health services on economic grounds, especially for their help in developing labour productivity in agri- culture and industry. It can therefore be expected that there will be an econ- omic justification for health services as well as a justification in the light of existing and future health needs and demands. Such economic thinking implies a certain change in attitudes and even in the health service itself. While, up to recently, the Ministry of Health tended to main- tain its traditional method of planning, it has now recognized the need for change and has established Department 13 as a special long-term planning group. Some of the functions of the new group were carried out previously, but conscious attention is obviously now being paid to new approaches. However , until the new department becomes fully operational, leadership in the economic aspects of health planning can be expected to come from the NPO. The National Planning Office (NPO) The Council of Ministers has a State Planning Commission which takes decisions in economic matters and prepares other decisions to be ratified by the Council of Ministers. The Commission is headed by the president of the Planning Office, who is also a deputy prime minister ; other members are the other deputy prime ministers, as well as the Ministers of Finance, Foreign Trade, and Labour, the President of the National Bank, and the Chairman of the National Office for Prices and Materials. The central planning agency of the Council of Ministers is the NPO, which also provides the secretariat for the State Planning Commission . The Office has 14 departments. Overall economic planning tasks are per- formed by the department of long-term planning and the department of economic affairs. Other departments dealing with overall economic and social 135 affairs are finance, investment and construction, and regional and sociocul- tural affairs. The other departments are either sectoral (industry, agriculture, transport) or administrative (secretariat , personnel and education, general admin- istration). The staff numbers about 500. The Office is aided by a research insti- tute for economic planning (80 staff) and a computer centre (200 staff), equip- ped with an ICL 4- 70 computer. In recent years the activities of the NPO in health planning have been motivated by the wish to increase the efficiency of health care. Without a sufficient number of adequately qualified auxiliary health personnel, doctors have to perform many duties that do not require medical qualifications. Modem training methods and developing health care technology now permit auxiliary health personnel to be trained for work pre- viously done by physicians. In other words, technological development calls for the transformation of the health organization in order to bring about a rational division of labour between physicians and auxiliary health staff. A number of the doctors employed by the national health service also have private practice. A considerable percentage of the general practitioners in the countryside also have a private dental practice and this contributes to the relative shortage of dental specialists, in contrast to the generally good supply of physicians. The NPO has worked out international comparisons regarding the relation- ship between infant mortality, the supply of doctors, and the supply of hos- pital beds at given levels of economic development. The studies were designed to establish optimum upper limits for the provision of health services. An in- teresting finding was that, beyond a certain limit , neither an increase in the number of doctors nor an increase in the number of hospital beds has a sig- nificant effect in diminishing infant mortality or in increasing life expectancy at birth. By contrast , an increase in per capita national income decreases infant mortality and improves life expectancy . Another factor influencing Jong-term planning is the fact that manpower is already in short supply. It is not expected that Jabour will be imported. Given these factors, it would appear that the required changes in attitudes and organization can only be brought about in the long term. A quantitative assessment of such changes has therefore to extend over a number of 5-year periods and to focus on specific modifications in health policies. Naturally , the required changes will only gradually pass down to the periphery. THE DEPARTMENTS OF THE MINISTRY OF HEALTH The new Department 13 gives direct support to the Minister and Deputy Min- ister of Health regarding matters o f principle on Jong-term epidemiological and re- source trends. It consists of a medical , economic, and info rmation group, and a national institute for o rganization , planning, and infonnation is responsible to it. The institute has sections for organization, economics, engineering, docu- mentation, and computer programming, and expects to have its own computer in the near future. Its presen t programme is focused on morbidity studies. 136 Department 6 now handles short-term and medium-term resource and budgetary planning, including construction, engineering, architecture, the supply of equipment, salaries and fees, and medical care for health personnel themselves. It is an operative programming unit for short-term plan imple- mentation. Both planning departments have a close working relationship with the other 11 departments of the Ministry. It is therefore of interest to indicate the functions of those other departments. Department I is responsible for personnel. Department 2 is responsible for the graduate and postgraduate training of all health workers and supervises all the medical schools. It works with the Ministry of Education and the county councils. Department 3 is concerned with the delivery of preventive and curative personal care. There are 36 national and state institutes, for example the National Institute of Surgery , directly responsible to it. All health services are paid for by the Government and are therefore free to the consumer. The only exception is that the consumer pays 15% of the cost of drugs and certain articles of medical equipment such as prostheses. The other 85% of drug costs is covered by social security funds, which also provide for pensions , maternity benefits, and sickness and disability payments. The insurance system also acts as a watchdog to prevent overprescribing by physicians. Department 4 is responsible for all maternal and child care and has an as- sociated maternal and child health institute. All deliveries are in hospital. Family planning is also organized by the department. One aim is to encourage larger families, as population growth has tended to slow down. Free abortion is permjtted only if clear medical or social criteria are fulfilled. Department 5 carries out overall epidemiological surveillance and environ- mental control through national institutes. At the local level the department re- lies on sanepids, stations for environmental health , surveillance, and control. Department 7 deals with disaster control and civil defence . Department 8 is largely a coordinating agency for pharmaceutical affairs. Attached to it is a national institute of pharmacology , which is mainly respon- sible for quality control. In Hungary pharmacological agents or drugs can be made available commercially or in any other way to the public only when officially permitted by the Ministry of Health. There is coordinated effort every year in pharmaceuticals by the department, institutions, and industry. The required quantities of drugs are estimated annually or semi-annually by hospitals and other inpatient institutions, and by pharmacies for drugs used outside hospital . The pharmacies belong to the national pharmaceutical in- dustry, which also manufactures drugs for export. Department 9 is concerned with aspects of social policy , especially for the elderly. Its main responsibility is for old people's homes and "nursing" homes, but varies from domestic aid to long-term institutional care. In addition, some financial subsidies are given to the indigent aged, such as for rehabilitation. Department 10 is concerned with ex tern al affairs, including arrangements for the travel and placement of Hungarian officials and fellows abroad, and for cooperation in international health affairs. 137 Department 11 coordinates the scientific research in the country as a whole . The research undertaken is mainly clinical, biological , and pharmaco- logical in nature, and is supervised in consultation with all other interested departments or institutes. Because of the teaching and other responsibilities of academics, most of the research is done on a part-time basis. Department 12 is directly linked to the Minister of Health. It has the task of creating legal rules and regulations in the health field. Relationships of the Ministry of Health with other agencies and institutions Apart from the various institutes associated with the Ministry of Health, the Health Science Council is a top-level advisory body appointed by the Minister with the concurrence of the National Academy of Sciences. Commit- tees within the Council may be organized by the Ministry or the Academy or by both. The committees are asked to review or undertake studies of prob- lems in particular fields and to advise the Minister. One committee directly concerned with planning matters is the Committee for Organization of Health Care. Members of the Committee come from government and medical departments of universities. They include medical and nonmedical health administrators , economists , the Chief Medical Officer of Budapest, and departments of the Ministry. External coordination is well illustrated by the liaison between Depart- ment 5 ( environmental control) and bodies outside the Ministry of Health. The department has the task of supervising the control of pollution, particularly where there is a possible health risk. Together with its institute of public health and the sanepid stations, it identifies sources of pollution. Because of the wide implications and different fields involved , one major body associated with the department is the directorate of rivers and lakes. Other ministries, such as those for urban development , industry , and finance, are also concerned with the longer-term problem of pollution. A council for protection of the environment was recently created and is chaired by a deputy minister. Of special interest is the role of the labour unions in protection of the working environment , mainly as regards safety and accident control. They cooperate with ministries but also have direct power to close down offending premises temporarily . PLANNING AND DECENTRALIZATION Hungary consists administratively of the capital, Budapest, and 19 coun- ty councils, one of which is that of the county of Pest adjacent to the capi- tal. The counties are further subdivided into municipalities and urban and rural districts . In the 1960s a policy of decentralization of services was initiated that gave the counties major responsibility for the running of various services, including education and health. Hospitals are decentralized down to the municipal level, depending on their size. Hospitals may be municipal , county , regional , or 138 national, the last two being the largest. National hospitals come under the direct control of the Ministry of Health , and for the most part consist of uni- versity hospitals and clinics or specialist institutes. They tend to be the most specialized units in the country. Decentralization is bound to affect the planning process. Thus, in the preparations for the 5-year plans, county councils and lower levels submit a situational analysis and an indication of future requirements to the Ministry of Health. This information is utilized by the Ministry in its discussions with the NPO. The NPO finally issues directives, especially regarding the development of health services, and allocates block budgets to the local authorities, who then plan for their level on the basis of these and more detailed directives by the Ministry of Health. The local authorities are thereafter free to use their funds as they will within the general national framework, except for national priority targets, which in the present plan are housing and hospitals. It should be noted that the choice of which departments in hospitals are to be strengthened or improved rests solely with the local authority. Counties have the duty of collecting local (municipal and rural) taxes. If taxes fall below a certain level, equalization grants are given by the Govern- ment. If a county is especially rich, it will receive no grant and may be called upon to subsidize other local authorities. Another feature recently introduced into the planning system has been the use of models to help study various options in health service delivery. The emphasis during this novel exercise has been on cardiovascular diseases, where it was found more economical to upgrade existing care facilities than to in- crease their number. BUDAPEST'S POSITION WITHIN THE NATIONAL HEALTH SYSTEM Budapest has a department of health directly responsible to the city coun- cil and technically under the supervision of the Ministry of Health. The city is divided into 22 districts, each with its own health section. Districts have an average population of 90000- 100000 (ranging from 60000 to 160000) , the total population of the city being 2 000 000. In addition, a large part of the adjacent county of Pest, with some 900 000 population, is also served, more than 50% of county patients being catered for. An allocation of up to I 0% of beds has been set aside to provide for people from other counties outside the catchment area.0 0 At present 9000 of the 24 000 physicians in Hungary are in Budapest, and the ci ty has 27 000 of the 85 000 beds in Hungary. Of these 27 000 beds , 15 000 are under the direct control of Budapest City while I 2 000 belong to the Ministry of Health, 4000 being operated by the university . The health institutions in Budapest provide for about 3 000 000 cases, mainly from Budapest and the surrounding areas. A special agreement has been made between the county of Pest and Budapest to assume responsibility for the county's patients. 139 Outpatient care For outpatient consultations the first contact is through the district physician. The average number of adult patients on a family physician's list is 2200- 2400, and although free choice of family doctor exists in practice most lists change very little. Free choice of family doctor ( district physician, general practitioner) is possible in certain geographical areas. In the capi- tal the choice is restricted to doctors practising in reasonable proximity to the patient's place of residence. Elsewhere an inhabitant of one town will obviously not be placed on the list of a general practitioner working in an- other. For outpatient referral, the physician passes his patient on to the dis- trict polyclinic, but in larger districts he has the choice of two polyclinics. The day's work consists of office consultations between 8 a.m. and 12 noon, with home visits in the afternoon. Every other day the home visits are made in the morning while the consultations are in the afternoon until 8 p.m., in order to make the doctor accessible to every inhabitant, irrespective of whether he works morning, afternoon, or night shifts. The district doctor may also give emergency care and certify absenteeism during the day. In addition he may receive visits from clients on special registers , e.g., for cardiovascular, gastrointestinal, endocrine, hypertensive, and respiratory diseases. For weekend duties physicians are combined in groups of seven or eight so that one doctor is always on call. For emergencies there is a separate service ; a physician from a hospital may visit by ambulance, if necessary, or a car may be sent to bring a patient to hospital. The physician usually has the benefit of a rented local authority house. He tends to receive less money than doctors in more remote areas. However, his qualifications for a Budapest post need to be higher than those of a general physician ; he must now have a specialization in internal medicine (50% of doctors are already specialized). In recent years , with the introduction of post- graduate training in general practice, it has also become possible to specialize in general practice. In each district there is I paediatrician for every I 000 children, including 90- I 20 under I year of age. The paediatrician is also responsible for preschool children and schoolchildren up to the age of 14 years. Care is both preventive and curative, including home visits by the paediatrician and by paediatric nurses or aides. The latter may carry out certain medical duties (e.g., in acute or emergency illness) . Such a paediatric service exists at present only in cities and towns with at least 3000 inhabitants under 14 years of age. In smaller com- munities and in villages it is the general practitioner who is responsible for child health. Preventive care for adolescents up to the age of 18, covering high-school or vocational training, is in the process of being organized . The third network of primary care services is that for industrial workers. On average there is I factory physician for 1600 employees. His primary duty is the prevention of work hazards and the immediate treatment of sickness or injury. He is empowered to issue initial sickness absentee certificates. He also 140 conducts examinations for entry into employment and regular routine exam- inations of all employees. At present he keeps records - like the family phy- sician - on cardiovascular diseases and on gastroenteric, endocrine ( diabetes), hypertensive , and respiratory conditions. For long-term care the worker is referred to the family physician or to the polyclinic if necessary. Regulations lay down that every factory or plant with at least 500 em- ployees must organize its own primary care system. Where the number of employees reaches 1800 a full-time factory physician must be appointed . In heavy-duty enterprises (e.g. , mining) the organization of a primary care system is statutory for 300 employees, and for 1200 employees a full-time doctor must be appointed to head the system. In addition to the district physicians, each district in the city has l or 2 polyclinics, usually I for a population of 70 000-80 000 and 2 for popula- tions larger than 140 000-160 000. It is planned to unify the administration for the larger populations. The director of the polyclinic is at the same time the chief of all outpa- tient services. Within the polyclinics are found at least 12 specialties. It can therefore be seen that polyclinics are outpatient referral stations to be used by the primary care personnel. In an emergency, however , the polyclinic does offer primary care. The specialists may also support the district physicians with home visits. Some technical supervision and continuing education are also carried out by polyclinic staff. Each specialist instructs district physicians in his own specialty. Every month district physicians are invited to meetings and con- ferences at their referral polyclinic to discuss cases and new developments ( e.g., in pharmaceuticals) . Among the preventive activities of polyclinics the first was screening for pulmonary disease . Each ad ult is required to undergo an annual miniature chest X-ray. The plan is now to increase this frequency to 6 months for certain groups at risk from lung cancer. During the last year 65% of the new tuberculo- sis cases and 50% of the lung cancer cases were detected by this method of systematic screening. Depending on age and sex, other screening is carried out for children and for mothers. Screening is also done in factories, for dental needs in children, and for syphilis in all hospital admissions, as well as for examinations prior to admission to nurseries, enrolment in schools, entering employment, and be- ginning military service. The completion of a project that studied a I 0% sample of the city popula- tion aged 40 years or more for their general morbidity pattern has been of value for longer-range planning. Hospital care After the Second World War hospital construction was concentrated in the counties rather than in the capital, in order to improve the balance between the city and elsewhere ( over 50% of all beds were in Budapest). As a result, although some renovation has been carried out, there is now considerable 141 overcrowding0 in all the city hospitals. One factor is the personal preference of consumers for Budapest. A second is that the adjacent county of Pest is largely serviced by the city. A third is that the investment share of the city was 7-8% rather than 20%, which would be more in line with the requirements of the city's population. Two-thirds of the hospitals administered and maintained by the councils in Budapest are under the jurisdiction of the City Council. The rest are run by the district councils. The university hospital (clinic) is a national institution. Six Budapest hospitals have been chosen to act as supervisory agencies for all the city hospitals. Their senior staff have been formed into working teams according to specialty and are now responsible for situational analysis, suggestions, and plan proposals. These are contained in yearly reports to the appropriate national institutes. The Budapest Department of Health also makes use ofa number of specialist subcommittees who advise on the requirements of its own hospitals. The next 5-year plan will place more emphasis on hospitals in Budapest than on those in the counties. It is expected that the investment in hospitals starting in I 975 will alleviate the present overcrowding. The main aims of the Department of Health , as developed by the 1976 and future plans, will include : (a) increasing the number of beds to 103 per 10 000 population ; (b) increasing the number of houses for the aged and of social homes, half of which will be for invalids and will require physicians ; (c) improving the links between all sectors concerned with health care delivery and health protection and increasing contact with the population on a more continuous basis ; (a) improving the physician/population ratio by, for example, providing I general practitioner per 2000 people at most ; and (e) increasing the number of support personnel , especially for community functions. One final issue of great importance in Budapest City is the reconciling of urban development , housing, physical planning, care of the elderly , and ge neral delivery of health services. Those concerned with spatial planning, regional planning, and special service planning are inevitably being forced to take overall account of all such factors and of one another's plans. This is all the more important because experience up to the present has shown that much more effort is needed before urban renewal can even match the requirements of the population for housing. a Some hospitals have a bed occupancy rate of over I 00%. This is most serious in the mental institutions, where the occupancy rate in a few Budapest departments reaches 130%. This does not hold good for the country as a whole. 142 BARANY A COUNTY'S POSITION WITHIN TH E NATIONAL HEALTH SYSTEM Some 3½ hours' drive from Budapest is Baranya County. The total county population is about 420 000, living in more than 300 villages and settlements. The ratio of rural to urban population is almost I : I. The county seat, Pees, has about 160 000 people. It is a university town with coal and uranium mining and various light industries. On the whole the county is somewhat better off than the national average. The county health organization is similar to that of Budapest. There is a county health department led by a chief medical officer, which administers the services and implements the planned programmes. The programmes are carried out at the various levels as described in the section on Budapest. Thus the front line in health care is occupied by the district physician, who serves an average of 2500 people. Each of the IO district physicians is associated with a polyclinic and a regional hospital, where supervision, advice, and referral services may be found. At this level there is an area paediatrician ( I for each county administrative subdivision, thus 5 in all). His duties are similar to those of paediatricians in Budapest. Once a week, however , his paediatric nurses ( of whom there are 160) contact all the children under their care .0 For women and infants in each catchment area there is a service provided by a mobile team at various central locations in the county. The team includes an obstetrician, a gynaecologist, and several nurses. They deal with pregnan- cies and give prenatal and postnatal care and counselling. One device for assuring attendance is that maternity benefits may be lost for defaulting. General practitioners also give family counselling to mothers. Specialized care in pregnancy is provided by the polyclinics and all de- liveries are conducted in institutions, with a paediatrician as well as an ob- stetrician in attendance. Since I 970 there has been a well-staffed special emer- gency ambulance service which has reduced the number of deaths following premature births by about 25% relative to other counties. On the industrial side there is a chief county medical officer, who admin- isters the service provided by industrial physicians. A point of special interest is that one major agricultural collective has a full-time medical officer attached to it. He carries out general practice and special occupational work, in a project that is collecting data to be used in establishing similar medical officers through- out the county . Each of the regional hospitals in the 5 county subdivisions has the usual specialties attached to it. Together with the Pees University Clinic, there are about 3400 inpatient beds in the county, i.e., 80 beds per 10 000 population. As in Budapest, the hospitals are overcrowded; the average length of stay is I I- I 2 days. Emphasis will therefore have to be placed on early discharge with outpatient care, homes for the elderly, and home visiting. To relieve district a Vaccination , including booster vaccination , is compulsory for BCG, DPT, smallpox, poliomyelitis, and measles. 143 physicians of some of the caseload that will result from this policy, the county is employing health visitors ; now about a third of the physicians have a health visitor attached to them, and the rest are expected to be supplied within the next 5 years. Investment is mainly geared to, and carried out according to, the national plan. It is therefore partly financed from national sources. Apart from "goal investments" (housing and hospitals for the next plan), the county is left to decide how it will meet the general plan directives. The mechanism for deciding is partly based on the chief county medical officer, who is advised technically by specialist committees of senior county health staff who meet each quarter. It is the county council, however, that takes the final decisions. Three-quarters of the total annual (recurrent) county budget is from local sources, the remainder from national funds. The health department receives about 36% of the total county budget. Financial reviews and revisions are carried out by the councils and the Ministry of Finance on an annual basis. Accounts and expenditures are first scrutinized at county level, and the information is then forwarded to the Min- istries of Finance and of Health. If the Ministry of Health believes that there is justification for extra expenditure and convinces the Ministry of Finance ac- cordingly, additional funds are forthcoming. If an institution or service saves money by efficiency, it can retain the savings as an incentive bonus. The general practitioner in Baranya County After the first 2 years of postgraduate work in hospitals, physician grad- uates have several choices: (a) they can remain in the hospital , take their specialty examination or board later, and continue to work there; (b) they can become staff of the polyclinic after specialization ; (c) they can become district physicians ; (d) they can become industrial (factory) doctors;or (e) they may join the public sanitary and epidemiology services. However, in the town of Pees the general practitioners are all already specialists in internal medicine. It is likely that all district physicians will be within the next plan period ; postgraduate courses for this purpose have al- ready begun . The medical school in Pees serves the whole of western Hungary, i.e., seven counties. Therefore the supply of physicians in Pees is above the national average. There are, at the moment, only three vacancies.0 a In the country as a whole there are 2400 vacancies for all posts, including 400 va- cancies for general practitioners required for more remote areas. As far as the patient is concerned, a maximum of 2 hours on foot anywhere in the county will bring him to a centre where he will receive adequate attention and, of course, he also has access to care through the telephone and the ambulance system. In Baranya County proper there were 56 vacancies at the end of I 973. 144 The average small-town or rural practitioner in the county - and else- where - works from an office or surgery provided by the local authority, with a house and garage attached. He owns his own car, and he can also purchase his own land and build his own house. He is assisted by one or more nurses and by a receptionist. He has a cleaner to maintain the premises. The equip- ment he uses is furnished by the county. It does not include an ECG machine or any very advanced laboratory or therapeutic equipment, but is adequate for his work as a provider of primary care. Specialist polyclinic and hospital facilities are available within a few kilometres. His salary includes allowances for night work and the maintenance of premises plus overheads, a car allowance , a location allowance, and other fees. In all , the allowances amount to about one-third of the whole salary, which comes to about 5000 forints in all (approximately 25 forints to the US$). He also derives an income in kind from grateful patien ts , which is not illegal provided that such gifts are not excessive. After office hours he may augment his income by taking on another job, or by caring for private patients, using his own equipment and serving persons not normally treated by him. The only major condition to be observed in this is that the county should be satisfied that his private practice premises are adequate. The pri- vate income is believed in many cases to be more than double the official income. For these reasons, once a physician has found a suitable area and is accepted by the county, he tends not to leave during his career. However , this does not mean mental stagnation. He is expected to attend conferences and meetings regularly and he must undergo refresher training from time to time. Emergency services Emergency services are organized as a special service with different types of vehicle, ranging from ordinary cars to highly specialized vehicles with sophisticated equipment. One problem has been that of communication. At present not all doctors are in contact with their base when ou t on a call. This is to be remedied by the use of radiotelephones. In the capital and bigger cities the majority of ambulances are already equipped with radiote lephones. It is in - tended to install them in every ambulance in the near fu ture. Doctors (usually those undergoing postgraduate training) travel in the vehicles if necessary. Attached to the service are a number of beds where such doctors can admit and treat less serio usly ill or injured patients. COMMENTS Like many other countries, Hunga ry has a fair mix of different medical personnel giving primary care, whether as general practitioners (district phy- sicians), paediatricians, or occupational health physicians. Much of the work is of a rou tine nature. Perhaps , in rationalizing primary care, it may be more 145 economical to have one cadre doing the jobs of all three and relying more on auxiliaries or paramedical workers for home visiting, preventive care, and long- term domiciliary management. The present information system has now achieved many of its objectives. There are large amounts of data on mortality, morbidity, and services ren- dered. It is unlikely that the picture will change substantially in the future. There seems to be, therefore, a case for reducing the administrative and storage functions by using sampling techniques. There would also appear to be room for "management by exception", i.e., requiring information only about sig- nificant deviations from previously set norms and standards. This, in tum, would be in line with the objective of decentralization. It is hoped that the relationships established between the planning group in the Ministry of Health and the NPO will continue to be fruitful. Rather than studies by each group, it would seem that studies carried out jointly by both groups would have a greater potential. It seems also that more health planners should be engaged in economic problems in the health field and more econ- omic planners in health problems. This would also reduce duplication of ef- fort and make the information on these problems more useful. It therefore appears that an interdisciplinary approach to health planning and training is required. Both formal and, especially, informal contacts would benefit from more frequent interchanges. On the training side it would seem that many of the planners and organizers on both sides, from the centre down to county level, could benefit from skills developed in each other's disciplines. The prevention of health risks such as traffic hazards and dangers at home and in everyday life could benefit from stimulation by the Ministry of Health and the local authorities. This would call for a more active involvement of these agencies in community life. Perhaps there should be more selectivity in the mass screening of groups and individuals. Screening of total age groups has proved neither very econ- omical nor rewarding in case-finding; concentration on risk groups has been more successful. ln the case of women the screening system appears to be rather fragmented. The vaccination programmes have been very successful. It may not be long, however, before it may be possible to cut down on some of the vac- cinations, especially for smallpox, which could result in considerable savings in time and money. The certification procedures for sickness absence seem to be over-elaborate, with their many checks and counterchecks. It may be sufficient to certify ab- senteeism only if it extends beyond 3 days, and to have the certificate made out by one physician only. Balneological resources are abundant in parts of the country. They could be associated even more closely with both rehabilitation for certain diseases and tourism in general. Foreigners with chronic ailments could be attracted for treat- ment at very reasonable cost, especially if other amenities were available. 146 VI THE USSR: MOSCOW AND THE LATVIAN SSR DB.S. Griffith 1 & H.F.K. Zb"llner2 In writing about health services and planning in the vast expanse of the USSR, it would not be relevant to quote national statistics at length, since the Union as a whole varies so extensively in geography, climate, and popula- tion density. Reference will there fore be made mostly to data on the State of Latvia . Furthermore, little reference will be made to planning outside the Ministry of Health, for the reason that health sector planning is fairly repre- sentative of the planning system as a whole . PLANNING AT ALL-UNION LEVEL Within the Ministry of Health of the USSR there are a number of boards relating to different fields, for example the Education Board and the External Relations Board . Each of these has a planning group. The principal planning group, however , is the Planning and Finance Board (PFB). This body , headed by a senior medical administrator, has some 30 professional staff, mainly physicians trained in management, economists, lawyers , and engineers. Their role is to coordinate planning within the Ministry, to receive and study plans from the Union Republics , to receive and study proposals from Gosplan (the State Planning Committee of the USSR in the country's principal socioecon- omic planning body), and to set norms and standards in the health field at all-Union level. These plans are passed to other ministries , especially the Ministry of Finance and Gosplan, to ministries of the Union Republics , and to other departments within the Ministry of Health itself. 1 Regional Officer for Health Planning and Evaluation, WHO Regional Office for Europe, Copenhagen, Denmark . 2 Health Planning and Evaluation Officer , WHO Regional Office for Europe, Copen- hagen , Denmark. 147 In preparing a new 5-year plan for the health sector , the PFB considers the existing norms and activities and decides, on the basis of past experience of changes in population characteristics and other factors , whether they are ad- equate to meet future health needs and demands. Having done this, it is then in a position to say which norms should be changed and in what way. The resources needed to adapt the capacity of the existing health service system to the up- graded norms are then determined. This is done first in terms of facilities, man- power, and equipment. As the various unit costs are set nationally, all the items can be costed and aggregated. This activity takes place at all administrative levels of government. The various proposals are passed upwards from level to level and the final decision always rests with the central authority. While the Ministry of Health is the highest technical body in the field of health, Gosplan has the function of coordinating and balancing all the sectoral plans and requirements. This implies that the proposals relating to norms and therefore to resources and the budget will not necessarily be accepted by Gos- plan. Nevertheless , it would seem that, for historical reasons, the share of the health sector in all Gosplan expenditures is approximately 6% (capital and operating costs). This figure may be slightly increased by capital investment by large industrial plants and collective farms in the construction of health facili- ties to improve medical services for their employees and members. The health plan may therefore have to be adapted to allow for such changes. This in tum may mean that the amount allocated for capital investment must take into account the possibility of additional financing from the above sources. Final agreement leads to the plan being accepted first by the Council of Ministers and then by the Supreme Soviet, which gives it the force of Jaw. It follows, then, that the agreed health service delivery norms and standards also become the legal instrument through which implementation and monitoring are to take place. It should be noted that the Republics cannot normally over- rule these legal standards once they have been adopted , because all financing is dependent upon them. This does not mean that everything throughout the Soviet Union is uniform. On the contrary, any Republic that can show a good case for some variation in its favour has a good chance of having its own particular norm requirements adopted by the Ministry during the period when the plan is being drafted.a To help in the preparation of norms and standards for health service man- agement and delivery, the Ministry of Health of the USSR utilizes a special re- search institution, the Semasko Institute. This Institute coordinates individual research projects at all-Union level on the organization, management, and utilization of health care, as well as epidemiological studies. It also conducts its own research programme in the same field, working in close conjunction with the PFB. While there are only some 36 physicians, economists, lawyers, and a An example of this was where a higher rate of utilization of dental care was identi- fied in a given Republic. This was taken as an indication of the need for a higher norm than elsewhere for the supply of dentists. 148 engineers in the PFB , the Institute has a staff of more than 500, plus computer facilities. This does not include all those research projects on which it advises or which it contracts out to various Republics . One of the main research and planning concerns is the differentiation of norms and standards according to local conditions. This can be exemplified by the adoption of standards related to the use of land and to urban planning. It has recently been suggested that polyclinics in cities in the USSR should be located no more than 30 minutes walking distance or 5 minutes transport dis- tance from the homes of a population it serves. For rural areas it has been proposed that collective farm units be drawn into more closely knit communi- ties so that more adequate health services can be provided. As indicated above, some of the work of th e Institute is subcontracted , so that various centres throughout the Soviet Union are engaged in research projects of benefit to the whole country and not only to an individual Repub- lic. Thus the management and cost aspects of a major specializing hospital in one city may be closely studied in order to derive optimal standards for hos- pitals of a similar type throughout the USSR . There also appear to be advances in the area of extended care facilities of varying types that reduce hospital costs by saving general hospital beds. THE LATVIAN SOVIET SOCIALIST REPUBLIC AND ITS HEALTH ADMINISTRATION The Latvian SSR is one of the I 5 constituent Republics of the USSR. It is relatively small in area ( 64 000 km 2) and in population (2 450 000). It is bordered on the west by the Baltic Sea. The capital city, Riga, lies at the mouth of the river Daugava (Dvina). Th e city's population is about 780 000, or roughly one-half of the total urban population. Of th e population of the Republic I 570000 (approximately 64%) live in cities and towns, while the rural population consti- tutes about 880000 people, with a density of 15- 19 per km 2 . Administratively the Republic is divided into 33 districts - 7 municipali- ties and 26 rayons. Each rayon has an urban centre and an average total popu- lation of 50 000. The municipalities include Riga , 2 other cities with about JOO 000 population each, and 4 towns with a population of 50 000 each. These are self-governing within the Republic. Each of the 26 rayons also has its own administration . Both types of local unit are administered at local level by executive boards responsible to the Council of Ministers and th e Supreme Soviet of the Latvian Republi c. This Republic, in contrast to the large r Repub- lics , has no intermediate administra tive units between the local authorities and the Republic administration; i.e., there are no obkzsts or krajs.0 a An oblast is an administrative d ivision with a populat ion of aro und 2 000 000; in a more populous Rep ublic a kraj resembles an oblast, but has disti nct ive ethnic gro upings. 149 The main growth areas are in industry. Most of these developed after 1945. They include electronics, shipbuilding, locomotives, construction, production of domestic appliances, and textiles. In the primary sector farming, fishing, and forestry play a major role. The road and rail network is well developed. Most of the Republic is flat, containing numerous lakes, and in summer these and several seaside resorts attract tourists. The population appears to be aging rapidly. The birth rate is at present about 15 per 1000. The crude death rate is some 11.2 per 1000 and the infant mortality rate about 16 per 1000. The life expectancy is around 71 years. (In contrast, that for the USSR 10 years ago was 66 years.) Of the population 22% are under 14 years. The death rate, standardized for the USSR, is 8.2 per 1000. The administration at Republic level is similar to that at the all-Union level. There is a Supreme Soviet, a Council of Ministers, a Gosplan , and a number of ministries, including that for health. Within the Ministry of Health the main departments are: - medical care, curative and preventive , other than maternal and child health care - maternal and child care, curative and preventive - sanitary and epidemiological services - mental health - manpower_ and education - drug control and distribution - medical supplies - planning and financing - health statistics - research and development. The municipalities and the rayons each have a chief medical officer (CMO), who is also the head of the principal district hospital in the local administra- tive unit. His principal deputy and second-in-command is the epidemiological and sanitary specialist for the area. Riga , as the capital city, has a city health department of a size proportionate to its tasks. In all cases these units are under the control and supervision of the Republic Ministry of Health as well as of their local executive boards. The CMO of each unit is responsible for all curative services in the administrative area, except for a number of institutions directly controlled by the Ministry , which include two research institutes, one for orthopaedics and one for experimental medicine; a teaching institute for physicians ; and a school for paramedical manpower. Further, the Ministry controls psychiatric, tuberculosis, children's, general, and orthopaedic hos- pitals, which provide outpatient and inpatient care . The main network of services in any rayon or municipality consists of a principal district hospital and associated polyclinics and outpatient services, with a number of epidemiological and sanitary stations. These are supported by smaller hospitals , medical officer centres, and feldsher stations, mainly in 150 rural areas. Services include screening and "dispensarization" follow-up for 70% of the population . In 1972 the Ministry recorded 22 mil)jon outpatient visits and 500 000 inpatient admissions in the Republic. Apart from these Ministry of Health facilities, a number of facilities have been established and are operated through the trade unions in line with Ministry standards. They are mostly for the workers themselves and deal with chronic con- ditions (excluding cardiovascular disease) and rehabilitative, convalescent, and balneological cases. The facilities consist of sanatoria , convalescent homes , spas and rest homes. In some cases um on members receive facilities free of charge; in others a payment of up to 30% of the cost may be requested. These facilities account for some 1600 beds out of a total of nearly 31 000. Within the Republic there are also services provided for their workers by various mjnistries. Th e Ministry of Transport, for instance, provides general ser- vices for its workers consisting of 1000 beds and 500 physicians. Of 9000 phy- sicians in 1973, 1500 were prud by other sectors ; another 500 were engaged in science, research, and adrrunistration. Working within trus system of health care delivery are a number of teachers and research workers connected with the various ins ti lutes, special hospitals, and major genera l hospitals . In Riga there are 28 specialty departments at the principal hospital of the Republic, and these groups combine with insti tute workers to form 17 special functional gro ups or bureaux, each of which studies particular major ilisease problems, e.g., cardiac conditions in different age groups and with different pathology. In order to study possible future changes in health care delivery and in the development of norms, etc., a computer centre was set up in 1971. This is one of the first of its kjnd in the Soviet Union and is associated with the pro- gramme of the Academy of Sciences of the USSR. Its first task was to study the existing data and norms, with the rum of finding methods of eliminating unnecessary information so as to make the data more useful for planning pur- poses. After the initial development of a general information system, the centre is proceeding to develop specific information systems in three planning and evaluation areas. These are: (I) the budgeting and accounting of institutions; (2) genera l operational health statistics; and (3) health service supply systems. Built into the computer programmes are data on demographic, geograpruc, economic, social , and transportation infom1ation which , toge ther with health utilization information and morbidity and mortality data, are giving a much improved description of the present situation and of likely future situations. A main reason for this research is to assist the Ministry to assess where and how far it is justifiable for Republic standards to deviate from national ones. The computer has already confirmed the value of reducing drastically the number of small cottage hospitals and has shown that there is an adequate net- work of communications and services to bring cases into the larger district and central hospitals of the Republic. Computer studies have also set the level of beds in central rayon hospitals at 220- 350 during the next decade. 151 It should be noted that all-Union Ministry of Health allocations to the Republic level may be overdrawn; for instance, in the present plan the aver- age is as much as 6%. However, if this extra cost can be justified by priority needs and if the general productivity of the whole national economy is higher than planned, additional allocations will be accepted by Gosplan without major obstacles. THE PLANNING PROCESS In the planning process two major and parallel routes are followed . The first is through Gosplan and the second is through the Ministry of Finance. The Ministry of Health of the Republic is related to both these institutions at Republic level. As far as Gosplan is concerned, there is also a relationship at rayon level. Within the overall goals and objectives of the 5-year plan, annual plans are prepared for each year. This process begins during the second half of the year in preparation for the following year. It begins at the rayon level, where pro- posals of individual units and groups of units are received. Even for the smallest unit there is a governing body of individuals belonging to the community served . They have the power of rejecting the advice of the technical personnel and they can also make suggestions or proposals that must be given considera- tion at higher levels. (There is a special unit in the Ministry of Health dealing with complaints and suggestions. It is obligatory for this unit to initiate action on any matter within I month.) The rayons then pass their proposals to the Ministry of Health of the Repub- lic , where preliminary discussions are held with the rayon chiefs. The plans are reviewed, if necessary revised and, finally , after consolidation go to the Gosplan of the Republic . Here the health plan is again reviewed in the light of the plans for all sectors. Before submitting the plan to Gosplan, the Ministry adds pro- posals for those institutions for which it is directly responsible (e.g., Republic central hospitals). Further negotiations may take place, during which Gosplan seeks to balance the claims and proposals of all the plan sectors. After agreement has been reached the overall consolidated annual plan is submitted for the approval of the Republic's Council of Ministers and Supreme Soviet. The same procedure is now followed at all-Union level , the Republic's health plans going to the Union Ministry of Health. Discussions and negotia- tions may again take place between the Republic and all-Union ministries. Particular attention is always paid to divergences from norms and standards, except in respect of the differential norms that relate to different Republics or parts of Republics. Next , the all-Union Ministry adds proposals for which it is directly respon- sible (e .g., for specific institutes) and the whole is submitted to the Union Gos- plan. This occurs in the third quarter of the year, when all Republic ministries gather in Moscow for consultations with their all-Union counterparts and with the Union Gosplan. 152 It should be noted that this process refers to the development of resources, including mainly manpower and materials, but not to fmance . Approximately 3 weeks later a process similar to the one just described is initiated , a budget document being sent to the Republic's Ministry of Fi- nance. This document is prepared according to the indices of the master plan for the financing of health projects (e.g., cost of a hospital bed or of a sanitary epidemiological unit). As the expenditure for previous years and the expected developments for the coming year are known, an addition is made accordingly. The budget proposals go through the same upward process to the Union Ministry of Finance and, of course, to the Union Ministry of Health . The fmancial specialists from the Republics then proceed to Moscow for discus- sions. As this procedure takes place only 3 weeks after that for the resource group, in effect it is mostly the same people who take part. All in all, this dialogue between different bodies at higher and lower levels takes place about four times until finally the plan, with its budget, is sub- mitted through the Union Gosplan to the Council of Ministers and to the Supreme Soviet of the USSR, where it receives full legal sanction. The decision regarding in1plemen tation is formally made at tile meeting of the Council of Ministers on the first Monday in January. Formal implementation laws are similarly passed at Republic level. Although funds can only be earmarked after the legal formalities have been completed, in fact most projects except for new major capital con- struction are able to continue or to start before formal allocations of funds are made . All-Union budgets are supplemented by Republic budgets from taxation on local industries and collectives. Each Republic also makes provision for the main- tenance ofa reserve fund to be used for unforeseeable expenditures. When overall plan targets are exceeded, financial and other resources can be committed to additional or lagging health projects. Other sources of funds are the trade unions and major public enterprises or collectives. They can, of their own accord, decide to allocate special re- sources to any sector, including health . All budgets are broken down into various classified subheads, for example maintenance, foods, drugs, and salaries. These allocations cannot be substi- tuted for each other unless permission is given at Republic or other appropriate higher level. Requests for reclassification appear to be quite frequent and follow the lines of the ordinary budget process. Assigned funds that are unused at the end of the year cannot be trans- ferred to tile following year. There is, therefore, an incentive to use up the al- located funds . This, as in many other administrations, tends to lead to an end- of-year spending spree. Finally , the whole yearly process is a mechanism for monitoring and evalu- ating the achievement of objectives and targets within the 5-year plan. The general principles for the 5-year plans are embedded within longe r- term (10 and 15 year) plans. Such perspective plans, like the 5-year plan, take account of changes and trends in demographic and healtll status patterns, in- cluding morbidity. The present perspective plan of the Republic Ministry of 153 Health has been projected up to l 990 and is adjusted to take in to account changes and trends in demand and in service quality . It can be revised at any time when a major advance in medical technology occurs. Some of the salient features are as follows. The population is expected to reach 2 627 000 in 1990 as compared with 2 450 000 in 1973. The expectation is that there will be a higher demand for inpatient se rvices. Accordingly, the level of beds in 1990 is forecast as 162 per IO 000 as compared with 125 per 10 000 in 1973 . For outpatient departments it is calculated that there will be 12.5 visits per person per annum in urban areas and 7 .5 rural visits per annum. It is ex- pected that the average length of hospital stay will increase. The reason given fo r this was the expectation that this would reflect the improved quality of treatment and rehabilitation services for an aging population. Thus it has been calculated that a total of 42 200 beds will be required in 1990, of which 41 000 will be under the charge of the Ministry. This implies the construction of facilities for 15 000 new beds. It is expected that most of these beds will be in large hospitals in towns and cities. The 1990 perspective plan calls for 11 physicians per 100 beds. It is im- portant to remember that all physicians in the USSR have a regular work schedule limiting their hours of work per day . In absolute numbers there will be some 4600 doctors. With regard to outpatient departments, it has been estimated that there will be 30 doctors per 10 000 urban population and 17 doctors per 10 000 rural popu- lation . In absolute numbers this will mean roughly 7300 urban and 1300 rural physicians. The overall physician/population ratio for all health services will be 50 doctors per I 0000 population , or approximately 1 doctor per 200 population. This implies , taking account of attrition, that the number of admissions to medical schools in the Republic will increase by some 12% before 1990. To support the physicians in delivering health services it is estimated, on a ratio of 3 paramedical personnel (as defined by the USSR) to I physician, that there will be 37 000 in these cadres. Thus, in all, there will be at least 1 health worker (physician or other) for some 50 people . AN EXPERIMENT IN MANAGEMENT AT RAYON LEVEL This experiment, which began in 1967, is a pilot project to increase the efficiency of day-to-day management at rayon level. If successful, it is expected that it will be introduced elsewhere in the Republic (and in other Republics). Its introduction will depend upon the managerial qualities shown by individual rayon CMOs. In brief, the project concerns the giving of additional powers to the rayon CMO to utilize funds with a view to improving the efficiency of the rayon health services. He is advised by a special committee consisting of the chief account- ant , a trade union representative, and a member of the Communist Party . No decision can be taken without consulting the memb ers, who also have the power to overrule the CMO. 154 In the budge t the total sum is fixed , as well as the sums specified for salaries, food, and drugs . However , the CMO is permitted to redistribute and utilize other budget items - for example . he can transfer sums from one head to the other with regard to such items as education , travel allowances , equip- ment and maintenance. He also has the right to carry over unused funds into the following fi scal year . Further , he may purchase additional dmgs and food provided that they are financed from savings elsewhere . Another innovation is the right to sell equipment at his own discretion and retain the proceeds for the rayon's needs . With regard to staff, he is permitted to change the specialist distribution of staff and alter their workload and functions. Finally, he is per- mitted to pay any o f his staff incentive bonuses. He can also use surplus funds for improving the living and recreational conditions of the staff. The preliminary results of the project, which is now being run under its third manager, appear to be promising. Following a decision to central- ize beds in the rayon hospital (now 300 out of 500 rayon beds), the bed occupancy rate has increased and has achieved the norms set for future use. A similar result has been obtained for maternity beds. Specialty assist- ance to the rural areas has been greatly strengthened. This is true for both inpatients and outpatients, and a higher degree of specialized rural care than that laid down in Republic norms is being achieved. While little sig- nificance can be attached to changes in mortality and morbidity , it is a fact that the decrease in mortality is somewhat more rapid than elsewhere. A useful index is that of "physician error", i.e., the accuracy with which a physician makes a diagnosis as checked by other physicians. This has dropped from 6% to 2%. On the whole, it is agreed that so far the experin1ent has proved to be successful and the authorities have been encouraged by the results. HEALTH CARE FOR CHILDREN AND WOMEN IN THE LATVIAN SSR Much attention is paid in Latvia to the care of women and children. Within the Ministry of Health one department is devoted to the planning, organiza- tion , and supervision of maternal and child health (MCH) care . The department is organized as follows: (a) head of department ; (b) deputy for paediatrics ; (c) deputy for obstetrics and gynaecology ; and (d) chief, unit of marriage and family counselling. These officials are assisted in their duties by various special supervisors. For example , the deputy head for paediatrics is special supervisor of all paediatric hospitals and is assisted by a supervisor for preschool institu- tions, one for schools and one for problems of infectious diseases. The function of these officials is largely managerial. The goals, objectives, and targets of the 5-year plan are known to them, as are details relating to nom1s , indices , financing , manpower, planned and ongoing construction, and equipment requirements. All these matters are covered in yearly and , sub- sequently , quarterly action plans. 1 t is then the task of the officials concerned 155 to monitor the various activities, to prepare their parts of annual and of longer- term plans, and to supervise and control all institutions down to and within the rayons. This constitutes double supervision, the CMO of each rayon also carrying out his own supervisory tasks . Paediatrics The Republic has at present more than 2000 children's beds for various types of care. These include surgical, cardiovascular, accident, orthopaedic, oncological, urological, nephrological, ophthalmological, ear, nose, and throat, gastroenterological, endocrinological , allergic, chest, haematological, and rheumatic. Altogether 20 specialties are represented and, of the beds men- tioned above, 774 are reserved for these special fields. In addition there are a number of beds for infectious diseases, for tuberculo- sis, and for psychiatry. In all, excluding the last 3, there are I J .1 child ren's beds per IO 000 total population. Including the other beds, the figure rises to 14.9 per 10 000 total population (22% of the population are children under 14 years) . The figure of 11.1 children's beds per JO 000 total population reached in I 972 was the all-Union target for such beds within the plan ending in 1975. The increase amounted to 0.8 beds per IO 000 between 1971 and 1972. MCH staff believe that this achievement has been responsible for the drop in the death rate of in fan ts from 16.0 per 1000 births in 1972 to 15.8 in 1973.0 At rayon level most beds are to be found in the children's department of the rayon hospitals. Specializa tion does not cover the whole range described above , but specialty treatment for chest diseases, rheumatic diseases, and oph thalmological conditions is available. In some hospitals endocrinology and nephrology are included. In cities specialty treatment is also available for seven or eight specialties. At lower levels , in the ucastoksb I paediatrician is available for children's care. The all-Union ratio is 1 : l 000 children; in Latvia a ratio of I : 922 children has been achieved. Children are followed up by the paediatrician, assisted by a paediatric nurse. Of the 922, 6.5%-9 .2% are below I year of age. With cover- age such as has been described it is readily possible in practice to see all in fants every month and at the same time to carry out a full progran1me of paediatric care for all children. In urban areas child polyclinics provide similar services. There are some JO I child polyclinics supervised through the hospital system and manned by paediatricians. Throughout the Republic other institutions are provided for child care , namely kindergartens and nurseries (often combined) as well as schools. These institutions are financed by the appropriate ministry, e.g., education or trade. The health care is provided through the MCH services. As has been noted else- where, the health personnel include trained nursery nurses. 156 a The figure for the USSR as a whole is approximately 22. b Communities of 4000-5000. For handicapped children special kindergartens and schools are provided , designed to fit such children for as fruitful a working life as possible . The ineducable are commonly ca red for in special ins ti tut ions. The hospital specialists and the rayon CM Os make a prominent contri- bution to child care . Apart from administrative supervision by the CMO, con- sultations and training are given to those at lower level by both specialists and CMOs. In effect, the system makes allowances for referral , both down- wards and upwards. Finally, as for adults , there are sanatoria for children with chest, rheuma- tic, renal , hepatic, and orthopaedic conditions. The usual period of stay in these institutions is about I ½ months, but long-term care is also given. Teachers of the Ministry of Education provide continuing education for children in sanatoria . Obstetrics and gynaecology Arrangements for the care of women operate in much the same way as those for children . In the country the primary contact is usually the feldsher midwife or the ul:astok physician. If some gynaecological condition is present the woman may be referred to the rayon hospital or , if it is more complicated, to the principal Republic hospital. In the cities the first contact is with the polyclinic physician or gynaecologist. Much attention is paid to pregnant women. The early diagnosis of preg- nancy by both laboratory and clinical methods is stressed. Feldsher midwives and ucastok doctors carry out prenatal examinations ; a schedule lays down that pregnant women should be seen once every month to the twentieth week. Of all pregnancies 80% are diagnosed during the first 3 months and about 98% are fo llowed up throughout pregnancy.a Account is taken of disease associated with pregnancy and of other conditions that are not associated with pregnancy but may cause complications. In all rayons and cities specialists are available for consultation. At-risk pregnant women living or working under difficult or unsuitab le social conditions are admitted early to sanatoria. All or almost all deliveries take place in maternity homes, now usually hospital departments. Standards for beds suggest 30% for cases with patho- logical complications, 20%-25% for follow up , and 45%-50% for all other deliveries. Special isolation beds are reserved for patients suffering from tuber- culosis, hepatitis, and venereal disease. All deliveries take place in the presence of a doctor, although he may deal only with complications. A major effort is being made to deal with premature births so that collaboration between obstetric and paediatric departments is very close. The transfer of premature delivery subjects to major hospitals is regarded as the optimal method for ensuring a reduction of one of the common causes of perinatal mortality. In the postnatal period the mother continues to receive attention in hos- pital and at ui:astok level. Cases of puerperal sepsis are transferred to isola- tion beds, usually in major hospitals. a The norm is I 0.2 visits in urban areas and 8.2 in rural areas. 157 Mortality owing to pregnancy or conditions affecting pregnancy is low; it is said to be about 0.33 per I 00 000 females.0 The major causes are nephritis, cardiovascular disease, embolism, and postpartum sepsis. No case of rupture of the uterus has been seen for over 3 years. Mortality in infants occurs mainly in the immediate postpartum period and during the following 3 days. Prematurity, congenital abnormality, as- phyxia, and intracrania1 injury account for most of it. The mortality declines after this period. During the first 3 months abnormalities continue to be the major cause of death. After this pneumonia takes a high place as a cause of mortality during the first year of life. Unit of marriage and family counselling The Latvian SSR has the lowest birth rate in the USSR, the latest figure being 14.5 per 1000 population.b This compares with similar and sometimes even lower rates for other European countries. National policy has included a new Jaw drawing attention to the need to increase the rate of population growth. The same law also provides more monetary assistance during pregnancy, extended maternity leave, higher allowances for families with several children, and job retention rights for over I year during and after pregnancy. In Latvia the Ministry of Health established a unit of marriage and family counselling in 1972. So far it is the only Republic to do so. The unit renders ad- vice to premarital and married couples ; it provides specialist advice on sterility and follows up pregnancies resulting from, or subsequent to, the giving of advice (no fertility drug has as yet been used). In the interests of family spacing, advice is also given and provision is made for the use of all contraceptive devices including the pill. Sterilization is advised if justified on medical grounds. Vasectomy is not practised. Appropriate gynaecological, genetic, and other counselling is given for matters of sexual pathology and congenital abnormalities. Investigations into the causes of the relatively low birth rate have been continuing since 1959, when a study of90 000 married couples was begun. The study has taken into account such factors as the number of dependants in the family, living conditions, urban as opposed to rural domicile , the profession of the wife, the ages at marriage, education, the family budget, and the desire to raise the child at home. A number of medical questions were also included. The families have been regularly followed up and much information has been gathered. However, because of its length and complexity , the study has not yet produced very many conclusive results. As might be expected, one finding is that, the higher the education and the family budget, the fewer the children. Other possible factors are probably the age structure of the population and the 0 Mortality rates in pregnancy , deliveries, complications of pregnancy and puer- perium, etc., in some other European countries: German Democratic Republic (1969) 0.9; Hungary (I 970) 1.0; Ireland (1970) 1.4; Netherlands (1970) 0.4; Sweden (I 969) 0.2; Scot- land (1970) 0.6. b The figure is 23 per 1000 for the USSR as a whole. 158 large proportion of females in the work force. For the USSR as a whole, be- tween 1960 and 1967 some 58% of the net increment to the employed labour force consisted of women, in large measure housewives. The main task of this unit is to encourage women and the public as a whole by an informed approach to plan and to increase their families. The Republic Clinical Hospital for Children This is the principal paediatric hospital for children in the Republic. It has 1100 beds; 600 beds are provided for specific specialties, 220 of which are for surgical cases. This is in accordance with norms and standards agreed upon for the plan period by all the authorities involved. There is an increasing trend towards more specialization, the lead coming from this hospital. The hospital is also used for teaching paediatricians and nursing students and it provides undergraduate, postgraduate, and other training programmes. This calls for a high quality of teaching staff, the chiefs of whom often hold professorial appointments. The hospital management is satisfied that the bed provision is, for the present, adequate. This permits better and more adequate care, in spite of the fact that the periods of stay are in general decreasing. This has been achieved by making more use of polyclinics for pre-operative and post-operative care and during convalescence. However, the average length of stay is still as high as 18.2 days.0 The reason given for this is the effect produced by the long dura- tion of stay of premature infants. The main causes of mortality and morbidity are as might be expected: congenital abnormalities, virus infections, staphylococcal infections (both hospital-induced and from outside), leukaemia, and injury. As already noted, pneumonia also takes a high toll of life in the first year. A major problem is neurological conditions such as spina bifida, especially their continuing care. In this hospital, as in the main rayon hospitals, child mortality is very carefully studied. The chief pathologist analyses all the deaths. Autopsies are performed on all hospital deaths in the main hospitals. The information ob- tained is used for clinicopathological conferences and acts also as a form of medical audit. The hospital performs additional functions through what is called the ad- ministrative and methodological department and through the different special- ists. These functions in fact bring the expertise of the hospital down to lower levels, where the organization of work in particular specialties is supervised by the individual specialists. The administrative and methodological department plays a supervis- ory, coordinating, and planning role. It comes under the charge of the deputy chief of the hospital. In consultation with rayon CMOs and specialists, methods of care and management of cases are standardized, training programmes worked out, and trainee selection methods established. The maintenance of a The standard for the length of stay is 19-20 days. 159 recommended norms and standards is checked periodically by the department. In cooperation with the CMOs, programmes of work and forecasts of future ac tivities based on mortality and morbidity in previous years are consolidated for planning purposes. In budgetary matters, where service demands have from time to time exceeded the resources, no difficulties have been experienced in obtaining additional allocations. EMERGENCY SERVICES IN RIGA With accidents, acute cardiac conditions, and other emergencies on the in- crease, a special service has been set up in Riga providing a full 24-hour service . Manning the service are l 46 doctors together with a larger number of other health personnel. A number of the staff work also in the hospitals but form special teams for action. In all there are 40 teams, with special groups for resuscitation , cardiac emergencies, toxicological accidents, midwifery, and paediatrics. These mobile teams carry special equipment. Teams of drivers and feldshers are available for other more easily handled problems. Outlying areas are served by aircraft. Helicopters are obtained on loan from the Civil Transport Organization . THE TRAINING AND USE OF HEALTH PERSONNEL OTHER THAN PHYSICIANS The paramedical training school, one of the oldest in Latvia (founded in 1902), trains health personnel other than physicians, the latter being trained at medical institutes. It provides basic training for f eldshers, midwife-feldshers, pharmacists, and dental technicians. Most of these workers are women, as is the case throughout the health professions in the USSR. In Latvia, for example, 85% of the doctors are women. Study programmes for each group are devised on an all-Union basis so that curricula are uniform throughout the USSR. The length of study varies ac- cording to the discipline and to previous schooling. For example, a girl can be accepted as a feldsher with less than 10 years' education; she is then required to complete a course of 3½ years. If she has a full high-school education, the course lasts 2½ years. The feldsher is one of the mainstays of the health professions. She ( or sometimes he) staffs many of the small rural stations, carrying out diagnostic, curative, and preventive work. Feldshers are also given postbasic training in such fields as anaesthetics, intensive care, resuscitation, paediatrics, and emer- gency care of road and other accidents. In effect , although supervised by doc- tors, they are also expected to act independently. Some feldshers are em- ployed in sanitary work in the sanepid stations. 160 Midwives are accepted only after completing high-school education. Many of them are assigned to feldsher posts. In Latvia they are regarded as being of higher quality than nurses. Their training lasts 2 years and they work in both rural and urban areas - in hospitals, maternity homes and , as mentioned above, rural feldsher posts. Their main duty is prenatal and pvstnatal care . Most deliveries take place in hospital in Latvia. No medical service for con- finements is more than 30 minutes away by transport. Pharmacists are of 2 kinds, those with higher qualifications and those with diplomas . The school in Latvia trains the latter. This is a 2-year course, as com- pared with the 5-year course for those obtaining higher qualifications. Dental technicians are recruited after full high-school education and undergo a similar length of training to the others. They are , in fact , dental mechanics, working in prosthetics only. The training school at present has 700 students and a staff of some I 00 tu- tors, 30% of whom are full-time. The staff includes doctors who also work in the hospitals, pharmacists, and teachers for general education. Much attention is given to practical work in each subject. For example, pharmacists devote 50% of their training to practical work. Feldshers regularly attend postmortem examinations as part of their training. The school makes a particular point of following up and keeping in touch with former students. Refresher and other forms of training are given at the school and in other institutions. Among those who receive training in the Republic, apart from those already mentioned, are nurses , paediatric nurses, laboratory technicians, radiographers, sanitary feldshers, remedial gymnasts, physiotherapists, and nursery nurses . A number of less well qualified individuals, e.g., disinfectors, are usually given inservice training. They are not taught by any institute or school. In Latvia, although the training courses for nurses and feldshers run along similar lines, the nurse is less well regarded than the feldsher. Nurses assist doctors, while feldshers have additional diagnostic and curative duties. Whereas nurses work mainly in hospitals, feldshers work in health posts, sanepid stations, emergency services, and industrial and agricultural enterprises as well as in hospitals. Feldshers and nurses who do well are encouraged to continue their career as doctors. They receive certain credits for their previous training and for their practical experience . This provides an eminently practical incentive for staff in these categories to better themselves. One other point to note is that students' organizations take part in nomi- nating the best students. The numbers of personnel required in each category as well as of teachers and physical facilities needed are estimated on the basis of anticipated mor- bidity, utilization of services , and targets for increasing ( or decreasing) cover- age in the light of the changing needs and demands of the population and of changes in general and health technology. Estimates for 1990 suggest that 140 paramedicals (now 95) will be required for every 10000 popula- tion. They will support some 45 physicians (now 36) per IO 000 population . 161 It should be noted that these figures are higher than the national standards, but they can be accounted for by the structure of the population. SUMMARY OF DATA CONCERNING THE PRINCIPAL REPUBLIC CLINICAL HOSPITAL, RIGA Beds Special beds Surgical beds Staffa Physicians Other health workers Nonmedical workers Others I 300 I 210 400 256 651 422 341 24 000 (+) 75 Annual admissions Daily admissions Origin of patients 28% from Riga 72% from outside Riga General surgery General medicine General obstetrics and gynaecology Neurology Ear, nose , and throat surgery Ophthalmology Thoracic surgery Departments Proctology Gastroenterology Urology Chemotherapy of cancer Kidney transplantation Congenital abnormal- ities Anaesthetics Number of visits by physicians to rayo ns in 1973 Specialties in consultative polyclinic Number of outpatients seen by specialists per annum Intensive care Pathology Radiology Physiotherapy Pharmacy Polyclinic Organization, manage- ment , and method- ology 948 32 30000 a Heads of departments are professors or other senior staff and are attached to the Riga Medical Institute. 162 Budget 1973 4 418 000 roubles, of which salaries account for over 50% Additional funds - central grant for equipment Access to trade union incentive fund 200 000 roubles Not specified The hospital operates in much the same way as that described for the children's hospital, with services provided both inside and outside the hospital downward to the rayons. Standards for local units at polyclinic, rayon, and municipality level are set in conjunction with these units by the hospital's organization, management, and methodology department. On the nonmedical side the work includes: - appointment and workload scheduling - monitoring of and communication between wards - medical documentation - machine accounting - maintenance - (in the near future) provision of centralized supplies and catering facilities. TRADE UNIONS SOCIAL INSURANCE AND MAJOR ENTERPRISES While there is no obligation to become a member of a trade union, in fact almost every working person joins. The unions , among other activities, look after the safety, health, and welfare of the working population. Medical workers and employers each pay 5% of the workers' salary to the trade unions that administer a social insurance fund that is used partly for sickness benefit payments to members and as such can be considered to be a part of social insurance. Other payments in the social field, e.g. , old-age pen- sions, are administered by the Ministry of Social Affairs. Sickness benefits are provided from the first day of absence, but only on the production of a certifi- cate from a doctor. Collective farms have their own social insurance funds. The collectives likewise provide sickness benefits for their workers. Another important role played by the trade unions is in providing from their funds expenditure for the capital construction of various health facilities. This can be done by levying, say, another 1 % from earnings. The facilities include sanatoria, rest homes, and balneological and physiotherapeutic centres. Here workers (and sometimes their dependants) can receive treatment for various chronic conditions and also rehabilitative care. In some cases no contribution to the institution is required, while in others different scales of payment are requested. Once these institutions are constructed the management and care are provided by the Ministry of Health. Collective farms may similarly provide special institutions for their own members out of their own funds. 163 Certain major enterprises such as the railways and other federal transport systems provide their own facilities. These are outside the control of the Min- istry of Health. Collective farms and large industrial enterprises within the Republic provide additional funds from their income to supplement the Republic's own health budget. Another function of the trade unions is the management of summer camps for members of the Young Pioneers Organization. This is somewhat similar to the Boy Scouts and Girl Guides organizations in other countries. In 1973 there were 234 such camps, at which nearly 65 000 children each spent 1 ½ months. Responsibility for the health of these children devolves upon the Ministry of Health. SUMMARY OF PROGRESS IN THE REPUBLIC The development of health services in Latvia has to be seen in the light of the advances made after the devastation resulting from the Second World War. Progress has been exceedingly rapid over the past three decades. One field in which considerable successes have been achieved is that of MCH services: the infant mortality rate was 15.8 per 1000 live births in 1973 and the maternal mortality 0.33. Two other areas in which advances have been made are in the physician/population and hospital bed/population ratios, which are now 36.8: 10000 and 125: 10000 respectively. In ad- dition, the Republic is achieving an appropriate standard of coverage of rural areas by physicians; thus, each ucastok has its own physician. Doctors who work in rural areas receive incentives in terms of salaries, housing, and pri- ority for cars. Furthermore, as the difference between urban and rural stand- ards of living becomes less marked, the physician no longer needs to look to the urban areas for certain amenities. The Republic has adopted a policy of giving priority to candidates for medical schools who come from rural areas. With reference to the pilot management study, which is one of 120 in progress in the Soviet Union, the preliminary assessment suggests that a new law may be forthcoming as a result of these experiments, thereby widening the scope of management on the institutional level. The targets for the first 3 years of the current 5-year plan have in several instances been more than met. In the final 2 years of the plan it is expected that greater centralization of hospitals and polyclinics will be achieved while at the same time the coverage of rural areas will be further improved. The pro- gramme will require the construction of additional hospital facilities , staff quarters, training institutions, etc., in order to realize these expectations. In the near future programmes for an automated drug supply and a finan- cial disbursement system for the whole Republic will be initiated. Computers will be increasingly used as an aid to diagnosis, treatment, and administration. Research is being conducted in these areas at present. 164 COMMENTS Several points soon strike the observer of the health service system in Moscow and in Latvia. The first is the very practical approach to problems. The second is the complexity of the steps taken in the production and implementa- tion of a plan. The third is the large number of women holding leading and responsible positions in clinical and managerial work. With regard to the first point, the system is to a large degree problem- oriented, being based on data that reflect health problems. These data relate largely to the demand for services but cover the whole field of health care. Compilation of the data is relatively easy in the USSR because the coverage provided by the health services is very wide and, with a unified service, it is easier to provide channels of communication throughout the hierarchy. Much has been done to uncover hidden pathological conditions among the popula- tion by screening surveys. By putting these two fundamen ta) data sources to- gether and then using them as the first indicators for planning, a baseline assess- ment of the mortality and morbidity of a given population can readily be obtained. It is also relatively easy to study the number and kind of services needed to deal with any particular condition. It is then possible to compile forecasts of the expected mortality and morbidity , to exan1ine technologies that may be able to change them, and to build the technologies into the ser- vices needed to meet the expected workload. Having estimated the future load , and knowing what services can be performed by different persons at different levels , it is possible to work out the investment required in materials, money , and manpower for a give n period. By working out annual plans within the broader framework of longer-term plans an evaluation mechanism is created that can assess achievements and make adjustments where required . The process of planning requires both horizontal and vertical action. At the lowest level the CMO of the rayon, his staff, the Communist Party , the unions, and the community are involved. There is a similar group of interests at Republic level , with the addition of Gosplan as the sectoral coordinator and the Republic 's Ministry of Finance as the watchdog on expenditure, the Council of Ministers and the Republic Soviet. At Union level the structure is repeated, with the addition of various advisory bodies and institutes. It is probably dif- ficult to avoid a situation of this kind in a country of the size of the USSR, but it may be wondered whether, in striving to involve as many bodies and institu- tions as possible, the system is becoming so complex as to slow itself down rather than to mobilize its resources as effectively as possible. Given a stable and highly experienced group of planners at Republic level, is it necessary for so much coordination and counter-checking to be done at Union level? How necessary is it for Republic planners to visit Moscow each year in order to justify their proposed annual programme? Why is it that the finance plan and the technical plan are prepared separately? Once a 5-year plan is agreed upon, could not the Republic carry out its part without reference to the Union authorities except when difficulties arise? As the years have passed the volume of data to be analysed has increased, as have the nonns and standards. While these have in the past proved of value, 165 they may tend sometimes to hold up rather than hasten progress. For example, it is understood that higher utilization rates can be used to justify the need for more personnel. They could , however, in some cases be explained by the practice of making unnecessary visits and hence may not reflect a true increase in the caseload . Also, there seems to be a danger in using norms and standards that tend always to require an increase in , say, the personnel. Aie the man- power policies beginning to show diminishing returns? Should not more studies be made in an attempt to optimize the personnel mix rather than to increase the absolute number of each personnel category? One other aspect of data collection that has caused reservations recently in some countries has been the value of mass screening programmes, where few positive findings are obtained and many negative data are recorded. As stated above , the amount of data now being processed must be very con- siderable (e.g. , the study of90000 couples referred to by the unit for marriage and family counselling). At the same time, the medical computer centre in Latvia began its programme only in 1971 . If this is so, the conclusion is that the health profession has tended to look on this particular innovation with some suspicion. However, as experience increases, it is to be hoped that the information system, the manpower mix , and plan justifications will be examined and analysed to the benefit of all. One point of interest to planners, as indicated in the section on planning at Union level, is the promising approach incorporating land use and popula- tion groupings. This is a break with traditional norms. Thus it is now being advocated that in cities no polyclinic should be sited more than 30 minutes walking distance (5 minutes by transport) from any individual. Promising activity in Latvia is the experiment in local management , whereby the rayon physician and his advisers are given much more freedom and budgetary discretion in introducing staff incentives and improvements in working conditions. The impression was gained that there was a certain reluctance about intro- ducing economic techniques into health planning. It is possible that in the past the health sector had few problems over financing (although it was stated atone interview that, as in any place, the funds asked for were almost invariably cut) . This may be partly because construction is part of production, which is given a high priority, and therefore the need for the health sector to worry about capital expenditure is not great. However , as construction requirements become less, all resource allocations may also be reduced. Furthermore , although the USSR is relatively self-sufficient, it must still be affected by world prices, shortages of im- ported raw materials , and rapid changes in technology. This may limit resources that would otherwise be made available for health. Also, in view of the rising life expectancy and the policy of increasing the population, growth demands other than those of the health services may reduce the health sector's share of the avail- able resources . It would seem, therefore, that planners would be wise to pay more attention to costs and to cost-benefit , cost-effectiveness, and cost-efficiency than they have hitherto done. Moreover, exceeding the plan targets is not necessarily better than just achieving them ;it may indicate an underestimation of targets and a failure to plan as efficiently and as economically as possible . Finally , experience in health care elsewhere has shown that supply creates demand . 166 As pointed ou t above, the health professions in the USSR seem to be com- posed largely of women. Those interviewed were obviously energetic, enthusi- astic, and capable. However , as in other developed countries, the ratio of phy- sicians to population tends to favour the urban dweller. Would such be the case if there were more men in the medical profession? The Soviet Union has produced an answer to the shortage of rural health personnel , namely the feldsher. Furthermore, the good feldsher has the op- portunity to advance by further study into the medical profession proper. This system may well be worth copying elsewhere. In Latvia the paramedical school trains feldshers for 2½ to 3 years, whereas nurses are trained for only 2 years. Much of the training for these 2 groups is said to be identical and might perhaps be combined. 167 VII SWEDEN D.H.S. Griffith 1 & H.F.K. Zii/lner 2 Sweden is a parliamentary monarchy with a population of about 8 000 000. The functions of the Crown are mainly confined to representation. The ul- timate authority of the State is vested in Parliament , which since I 971 has consisted of a single chamber of 350 members who are elected every 3 years. Bills are referred to the appropriate parliamentary committee before discus- sion in Parliament. The government executive at the national level is the Prime Minister together with his Cabinet, which he appoints from among Members of Parliament. The collective responsibility of the Cabinet is policy formulation rather than policy execution, especially the preparation of legislation and of the national budget. The Prime Minister and the 12 ministers each have, therefore, only a relatively small staff. Coordination is ensured mainly by the Cabinet Office. The national boards (or agencies) are the administrative branches of the Cabinet and the relevant ministry for the execution of policy at national level. These boards have more or less autonomous authority from the Cabinet. Four ombudsmen are appointed by Parliament to watch over the courts and the civil service. They are empowered to investigate and act upon individual com- plaints of bureaucratic injustice. The Government is represented at county level by provincial boards. The most important provincial board is the Governor's Office , which is responsible to the Ministry of Physical Planning and Local Government but administers the policies of various national ministries. The Governor heads the civil service administration office. He is appointed by the Cabinet and assisted by a I 0- member lay board, half of whom are appointed by the Government and the remainder by the county councils. For some activities certain boards are directly responsible to their respective national boards. 1 Regional Officer for Health Planning and Evalu ation , WHO Regional Office for Europe, Copenhage n, Denmark. 2 Health Planning and Evaluatio n Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 169 There are two civic levels of local self-government which are independent of each other. These perform well-defined functions under their own authority and also carry out tasks which the State has delegated to them. The State, through its national and provincial offices, exercises supervision over and gives guidance to self-governing and delegated activities. The number of primary divisions of local government (the municipal- ities or primary communes) has been gradually reduced from about 2500 in 1950 to 278 in 1974. This reorganization was brought about to make their activities more viable. These activities include education, welfare sup- port, the care of children, the elderly, and the handicapped, local construc- tion, fire prevention, and various recreational and cultural activities. The secondary divisions of local government are the 23 counties or secondary communes.0 The largest task of the secondary communes is health, medi- cal, and dental care. Primary and secondary communes have a council, i.e. , basically a local parliament for decision making. The councillors are elected by the public every 3 years on the same day as the Members of Parliament are elected. The administration of the commune is by the executive committee of the council and various other more specialized boards and committees of the council.b The communes are empowered to tax residents' income at a rate deter- mined by their councils. Other revenues derive from grants-in-aid and sub- sidies from the State government as well as from charges and fees, rents and interest, real estate transactions, etc. The direct tax pressure on the population is high. The cost of services including health is made explicit, since individual tax statements are item- ized in relation to county communes as well as to the other two levels of government . There is a Swedish association of local authorities (primary communes) and a federation of Swedish county councils. Both organizations act as a national lobby, negotiate wages and working conditions for commune workers and officers, and carry out inquiries of various kinds. The federation em- ploys about 250 persons (as compared with 100 employees in the Ministry of Health and about 800 employees in the National Board of Health and Welfare). The federation also takes an active part in the attempt to lower the costs of health and medical care, one example being its initiative in setting up a com- mon organization for the supply of equipment, another its study of a central information system (in terms of several linked data banks) that would ensure 0 In addition, the primary communes of Gothenburg, Gotland, and Malmo act as secondary communes. They are also called county boroughs. This makes 26 counties in all. b Any member of a local community can complain about decisions by his local government to the Governor's Office . He can appeal to the Supreme Administrative Court of Sweden if he is not satisfied with the decision of the Governor's Office. 170 confidentiality but be able to follow up all patients and record their current episodes of illness and check-ups. This could be expected to lead to better use of the scarce supply of health personnel. The overall structure of Swedish government at the different levels is sum- marized in Fig. 1. Fig. 2 shows the major contributors to the social services, including the health service. Sweden covers a large area (nearly 500 000 km2) and has an average pop- ulation density of only 20 people per km2 . The population, however, is far from being evenly distributed : only about one-seventh live in Norrland, the north part of Sweden with more than half of the land area, while more than a third live further south in and around the cities of Gothenburg, Malmo, and Stockholm. The Swedish population is increasing only slightly each year (about 15% from 1960 to 1975) but the number of people over 65 years is rising rapidly (by about 40% between 1960 and 1975). The number of women in the labour force is relatively high and has been growing continuously. This alone has not satisfied the demand for labour resulting from the rapid expansion of industry. Considerable immigration, notably from Finland , has therefore taken place. About 1 child in 15 under the age of 12 years is an immigrant. Fig. 1. Overall structure of Swedish government Parliament Ombudsmen Cabinet National boards Governors of provinces Primary commune councils Secondary commune councils Communities ( including parishes) 171 --i Fig. 2 . Major contributors to the social services N Parliament Government Departments The birth and death rates in 1972 were 13.8 and I 0.4 per 1000 popula- tion respectively. The main causes of death were cardiovascular diseases, cancer, and accidents. NATIONAL ECONOMIC PLANNING National economic planning comes within the responsibility of the secre- tariat for economic planning of the Ministry of Finance. The economic 5-year rolling plans are merely indicative and may be better described as "economic surveys". The economic plans are largely a summary of individual forecasts on a national scale, while their implementation depends on decentralized public and private planning and execution. One main purpose of the national plans is to foresee the overall financial implications and feasibility. When the communes prepare their own 5-year plans they assume constant prices, wages, and import and tax capacities. When the Ministry of Finance receives the plans, as weU as plans from public enter- prise and plans (investment intentions) from the private sector, it has to cal- culate the likely impact of aU these together on prices, wages, foreign trade, etc. , and to adjust the plans accordingly. Behavioural parameters become more and more important in plan fore- casts. The ordinary wage earner already pays a top tax rate of 50%-60% on his wages. It can easily be seen that higher tax rates would lead to more tax evasion, a reduced labour supply, and a lower work effort or to more inflationary demands for wage increases. Forecasts can help the Government to take avoiding action, for example by indicating the need for a ceiling on the ag- gregate income tax levied by aU three government levels together. Another main purpose of the national economic plans is coordination of resource supplies and demands across economic sectors through econometric input-output analysis. In the past health plans were over-ambitious in their call for additional physicians and investments. Through the economic planning process, however, the health planners have learned not to be more ambitious than the education and investment sectors allow. The State cannot interfere much with the detailed plans of the county communes. It can, however, use general fiscal and monetary policy measures and - in conjunction with the National Board of Health and Welfare - ration or control major investments anJ key manpower distribution in the health sector. At present intersectoral economic planning is conducted only at the na- tional level. Previous attempts at regionalization (at the level of the six macro- regions) have failed, since the economic base of such regions can change very quickly when a large enterprise is established or closed down , because, for example , of changes in international markets. The planning council in each Governor's Office , which includes rep- re sentatives of the local government and of the private sector , carries out some economic planning. Provincial planning, to be sure, is aimed at pro- moting the economic development of the county and contributing to a more 173 equitable distribution of social services, social security , and living standards. It lacks, however, a good deal of the information it needs, is usually of a low analytical level, has high margins of error, and is more multisectoral than intersectoral in nature. Provincial planning in practice, therefore, is limited to suggesting possible uses of grants-in-aid and other State funds for regional development and to supporting decisions on the allocation of loans for residential construction and on permits for the siting of facilities. There is no genuine regional planning for socioeconomic development in county and municipal communes. THE HEALTH PLANNING ROLE or THE NATIONAL BOARD OF HEALTH AND WELFARE The Minister of Health and Social Affairs, as the political head , bears the responsibility for health matters. Within the collective responsibility of the Cabinet he has to ensure that the delivery of health, medical , and dental care is in line with national guidelines and priorities and preserves an equitable intersectoral and geographical balance . On the other hand, it is the county communes that are responsible for the planning, financing, management, and operation of personal health services - save for most school and occupational care - and of care for the mentally handicapped , nurse training, and some other educational and social activities. The State influences the county communes through appropriate legislation, incentives, and controls. It is a special feature of Sweden that these functions are divided between the Ministry of Health and Social Affairs and the National Board of Health and We lfare (NBHW). The Ministry of Health and Social Affairs is a small office with only I 00 staff. Its functions are mainly politico-legal, such as the prepara- tion of and submission of bills to Parliament. The NBHW is the national administrative organization for health and social welfare services and employs a staff of about 800. It is responsible for promoting, supervising, and controlling the work of the county communes in health and welfare, within the framework of the laws on health and according to national priorities. The National Board of Occupational Safety and Health, which also has about 800 staff members and is under the Ministry of Labour, has similar functions in the field of occupational health and safety. The activities of the NBHW are directed by a lay board which is chaired by the Director-General. Half of the lay board membership consists of Members of Parliament, the other members being appointed by the Prime Minister, mostly from institutions and interest groups within the health field. Further guidance for the NBHW is provided by the Scientific Advisory Panel. The administration of the NBHW is service-oriented and includes depart- ments of health and social care, short-term care, long-term care, and planning and ad ministration (Fig. 3). The head of the department of planning also acts as coordinator and liaison for the other departments. The department of health 174 -..J V, Fig . 3. The National Board of Health and Welfare I- I S . "f " • I Lay board - - - - - - - - - - - - - - -1 c1ent1 1c Advisory Panel 1 Department of health and social care Environmental health Social care of children and adolescents Dental care I Director-General 1-+-l Deputy Director Department of short-term care Ambulatory care Somatic hospital care Psychiatric care Care of alcoholics and drug addicts Department of long-term care Long-term re - habilitation Care of the men- tally handi- capped Social and forensic psychiatry Care of the elderly and socially dis- advantaged I I I I I I I ________________ ! I Permanent Advisory I l Health Planning : : Aavisory T>aneltor - -: 1 Emergency and 1 1 ___ Committee __ 1 I ,.. Wartime Planning _ 1 I I I Department of planning Health man- I Emergency and power util - I wartime I ization and I planning training I Emergency Overall service I staff reg ist ra- planning I tion and I Health statis- I training tics I I Department of administration Legal matters Pharmaceuticals Office and personnel man- agement Budget and payroll Public relations 1 _ __ ___________ L ____ _ ____ ____ I _________________ I ___________ _ _____ I and social care and the department of plan ning are the ones most intimately involved in the preparation of alternative plans to be submitted to the ministries and political bodies and in the implementation of the plans approved. The NBHW prepares general guidelines for all health personnel. It is the ex pert agency in matters of hygiene and medicine and has the author- ity to suspend or revoke licences . It also guides the county communes on plans, to be coordinated in keeping with national policies, which besides the yearly budget consist o f 5-year financing and implementation plans, JO-year to IS-year plans comprising a baseline, goals, and the financial re- sources required, and 30-year development outline plans that provide a view of the community development desired. It expresses its opinion on the plans of the county communes, but the latter have in ge neral the last say in the ap- proval of local plans. However, there is direct NBHW control over resource allocation for all re- investment and new investment, especially the construction and equipping of new hospitals and large health centres. Most important of all probably , the Board has control over the allocation of physicians and dentists to new posts and residencies. The initiative for new capital investment and medical and dental posts and residencies, however , has to come entirely from the county communes themselves. The National Health Planning Council is an interministerial council related to the Ministry of Health and Social Affairs. Its members are the Director- General of the NBHW ; a representative o f the Federation of Swedish County Councils; the Deputy Secretaries of Finance, Education, the Interior , Local Government , and Physical Planning and of the Cabinet Office ; the Directors- General of the National Boards of Education and of Labour ; and a representa- tive of the Swedish Association of Local Authorities. The NBHW acts as the secretariat. After approval by the Council , investment and staff priorities are forwarded to the Cabinet and finally to Parliament for annual approval. Propo- sals are also submitted to the Commission on Postgraduate Medical Education, which controls the total number of new physicians and dentists in the count ry , and to the Labour Market Board, which controls capital investments within the sectora l limits set by the Ministry of Finance . This planning and regulation pro- cess ensures that county communes follow the principles of explicit national priorities and of equitable distribution. Future prospects as seen by the NBHW The Ministry of Health and Social Affairs appoints a regional medical officer in each (county) province, who deals mainly with public health affairs and therefore controls and supervises health activities in primary communes and some ac tivities in county communes as well as private practitioners and nursing homes. He is technically responsible to the Ministry of Health and Social Affairs but reports administrative ly to the governor of the province . The conventional regional medical officer is tending to be phased out both for lack of demand for his functions and skills and for lack of supply of suitable can- dida tes. The NBHW is planning to change his functions to lay greater stress on epidemiology and on consu ltation about the utili zation of different and 1 7 (1 broader-based health resources, so that he can advise county communes as a local governor's board representative. These modern requirements are al- ready reflected in the training programme of the Nordic School of Public Health in Gothenburg. County communes have also formed 7 multicounty regions for hospital care. One specialized hospital, usually a university hospital but always with training and research functions, is used as the major referral hospital within the region . The reason for this step is the high cost of, and relatively small need for, expensive equipment and superspecialties . The ideal of the NBHW is a completely regionalized system. This envisages a primary health care district with a population of 10000 to 40000, having a health centre with general practitioners and some outpatient specialists as well as a nursing home ;0 a county district with 60 000- 100 000 people, having a district hospital with some 4-6 specialists (in internal medicine, surgery, anaesthetics, and radiology) ; a county commune, with 250 000-300 000 people, having a central hospital with 15-20 specialties ; a regional level with about I million people, having a regional hospital with 30-35 specialties; and a national level having the Karolinska Hospital as the ultimate point of referral. At present the care system, including outpatient care, is hospital-oriented. The new policy favours health centre ca re. The highest priority up to 1985 will therefore be given to the development of primary care in the community . The NBHW has set a targe t for 1985 of 4 to 4.5 visits (including preventive care visits) per person for public (county commune) district physiciansb in health centres and other primary care stations. The corresponding figure for 1972 was only about 1.4 visits (exclusive of preventive care visits) , half of which were visits to private physicians' offices. About the same number of visits ( I .4) took place at outpatient departments of hospitals . The NBHW would like to develop public health stations , especially health centres , and keep the private sector at its present size. About 10%ofphysicians, mainly in the big towns, are in full-time private practice. Mixed private and public practice is not allowed in Sweden, but the average age of private phy- sicians is quite high ; about a third are older than 65 , the retirement age for public practice . It may well be that, o n retirement , physicians turn to private work. An incentive to work in the public primary care service is the salary adjustment that makes allowance for the number of hours worked. Refo rms of the insurance system since 1975 are tending to eliminate the financial differences between private and public practice. The private practi- tioner (usually a solo practitioner) receives a token payment from the patient , as does the public district physician. However, he must pay for his own em- ployees. Th e trend is therefore towards public practice. Some recommendations 0 A nursing home in the Swedish co ntex t is an in stitution where patients can be given more C!>. tc nsivc nursing care than a t ho me. b The di stri ct physician is a doctor who provides primary medical care o utside a hos- pital. I le is employed by the co unty coun cil. As noted above, district physicians are in shurt supp ly. 177 to hasten the advent of public primary care are being developed with the Na- tional Institute for the Planning and Rationalization of Health and Social Welfare Services. The output of medical schools will have to be doubled to increase the number of employed physicians during the 1970s from 10 000 to 20 000. At the same time the present number of hospital posts for physicians will have to be frozen. General practitioners would be regarded as specialists, with the same salaries as hospital specialists. Working hours for hospital-based and general practitioners would also be made comparable (younger physicians in particular emphasize the value of leisure) . Also , the role of the regional health officers in the Governor's Offices will have to be changed so that emphasis is placed on comprehensive primary care and on environmental health matters. Other priorities are as follows: long-term services have to be expanded, since in 1985 more than 17% of the population will be at least 65 years of age; psychiatric care has to be better coordinated with physical care ; and acute in- patient care will have to be more concentrated and better primary care provided so as to decrease the admission rate to, and length of stay in, hospitals. It should then be possible to reduce the average number of acute beds available per 1000 population from 6 beds in 1972 to 4.5 -4 . 7 beds in 1985 . OCCUPATIONAL HEALTH On the occupational health and safety side, the Industrial Safety Inspec- torate of the National Board of Occupational Safety and Health has I 9 regional offices for factory inspection, each headed by a qualified engineer. There are also centres for occupational medicine attached to regional hospitals in 4 of the 7 regions of the country. Large plants with more than 1500 employees have their own service. Many medium-sized factories have evolved shared services. There are already some 150 occupational health centres, with preventive and curative functions, run by local industries throughout Sweden. This is in effect a nonpublic venture, but is often organized by industry , trade unions, and local communes. Altogether about 600 full-time physicians work in these centres and in the large plants, and cover about 1.2 million out of 4 million workers. Most of the working population not covered by occupational health ser- vices are employed in small plants. A few pilot studies on health care and its organization in smaller industries are at present being carried out by the Na- tional Board of Occupational Safety and Health. There is currently some discussion about who is responsible for organizing occupational health services in smaller plants. The county communes feel that they are responsible for the medical side; the trade unions and employer associations want to preserve their role in ensuring not only technical safety but also the prevention and treatment of illness among workers ; and the primary communes claim the role of maintainng social and environmental hygiene. The main forum for this discussion is a national delegation chaired by 178 the Director-General of the National Board of Occupational Safety and Health , which includes members of the NBHW, the local communes, the trade unions, and employer associations . THE NATIONAL INSTITUTE FOR THE PLANNING AND RATIONALIZATION OF HEALTH AND SOCIAL WELFARE SERVICES This Institute (SPRI) was set up in 1968 to act as a consultant agency for the county communes, the Federation of Swedish County Councils, and the NBHW. The main purpose , in effect , was to check the rising costs of medical and health care. Two-thirds of its funds are provided by the Federation of Swedish County Councils and one-third by the State (NBHW). At present the Institute has a professional staff of about 100. The planning department of the SPRI has no physicians on its staff but uses economists , systems analysts, operational researchers , sociologists, and statisticians. Data-processing is carried out in the organization department, which also develops health information systems, especially for the budget and for personnel. Since its foundation the Institute has developed a methodology for fore- casting health care consumption , with special emphasis on outpatient care and medical care costs. In 1971 a model for long-range planning was developed , which the county communes found useful when reviewing their ideas for the next 10- J 5 years. This model, which is largely based on an aggregate of in- dividual plans, needs further research and development, in particular so that other sectors of health in1portance can be included. Research is also needed on the application of modern organization and management theory to health services and the improvement of long-term planning systems. On research matters the SPRI cooperates directly with the county com- munes, which have research departments of their own. Until recently the research emphasis was on inpatient care, since there is a lack of outpatient data in many county communes. To improve the information base on out- patients a pilot study on a commune is being conducted by the University of Uppsala. Another pilot project concerns programme budgeting in the Malmohus County Council. Financial data regarding health care outside hospitals are easier to obtain than epidemiological data on care utilization . The suppliers of services in the health care system send claims to the social security offices, on the basis of which funds are transferred to the health care system. To improve its internal organization the SPRI is now making wider use of task forces. One task force, for example , is now concerned with the evaluation of policy changes in the organization of outpatient care that have been either implemented in the county communes or proposed as a matter of policy since 1969. For example , it had been proposed earlier that specialist physicians should be attached to health centres. It is now seen that there will not be a 179 sufficient number of specialists available to satisfy both hospital and health centre needs. Another earlier proposal that required modification was the change from capitation fees to fixed-salary payments for physicians, since this led to physicians working fewer hours than previously. The modification adopted takes the form of financial compensation for overtime . In addition, research is being conducted into ways of improving communication between patients and providers. The SPRJ conducts some studies on "standards" for the diagnosis and treatment of selected well-defined diseases . These standards are fed back to the county communes and their health institutions for further discussion. It is not thought possible to develop such standards for more than a few diseases. More- over, better procedures are often already known locally, so that it is felt to be more important to carry out research in to the reasons why local physicians decide not to utilize such standards. Decision models in therapy will therefore have to be developed . In this connexion , the SPRI is against the wide applica- tion of mass screening in view of its low yield and high cost. It is studying screening activities for individual diseases on a target population and has shown, for example in a pilot study in the hospital of Bor~s, that indiscriminate , as opposed to selective , rehabilitation yields little economic benefit while being at the same time quite costly. The SPRI does not deal with environmental and occupational health in its research, nor does it carry out medical research. Research in these fields is sponsored by the NBHW and the Medical Research Council and is car ried out mainly by universities. Hitherto the SPRI has not taken an active part in the coordination and guidance of such research. It is, however, pooling all the rele- vant information from such research studies for its own use . f.lNANCING OF HEALTH AND MEDICAL CARE The net public expenditure on personal health and medical care amounts to about 7% of the Swedish gross national product. The total operational expendi- ture is closer to 8% if medical services in industry, private medical and health expenses, and care administrative costs are also taken into account. In addition, there is the ex pen di ture on the training of health manpower , health and medi- cal research, the development of drugs and other medical supplies, and con- struction and equipment. The investment in health and medical care amounts to about 0.8% of the gross national product. Of the operational public expenditure on the delivery of health care 63% is derived directly from the 26 county communes and boroughs, 22% from the State government through the Governor's Offices , and 15% from the national social insurance through its 26 regional offices. Since the State subsidizes the insurance fund to the extent of about 16%, the actual State share of expendi- ture on care is about 24% and that of the insurance fund about 13%. The latter is financed from employers' contributions (about 60%) and employees' con- tributions (about 40%). 180 Capital investment for health care is provided by the county communes (85%) and the State (15%). The county communes spend about 79% of their operational budget on health and medical ca re , 8% on the care o f the mentally retarded , 5% on education and training, 5% on social services, and the remaining 3% on di- verse activities. Approximately 10% o f the to tal budget is spent on buildings and equipment. The income of the county communes is made up as fol- lows : about 55% comes from their own taxes on the income of commune residents, about 22% from the State (9% in the form of equalization grants and tax compensation and 13% in the form of subsidies for priority pro- grammes), 14% from loans and other sources, 6% from regional insurance offices, and 2% from patients' fees. From the above figures it is evident that the employer and employee contributions to the national social insurance scheme finance only a small portion of Sweden's health and medical care.0 MALMOHUS COUNTY COMMUNE: ITS PLANNING AND RESOU RCES Malmohus County is situated in the ex treme south-west of Sweden. It in- cludes 21 primary communes with a total population of nearly 750 000 people. The Malmohus County (or secondary) Commune, however, covers about 500 000 people , since it excludes the city of Malmo (population 25 0 000) , which acts as its own secondary commune (county borough) . The seat of Malmohus County Council is in Lund. The Malmohus County Council is an assembly of I 09 elected councillors, with smaller locally elected executive committees as its main instrument of control. The administration of the County Commune has about 450 em- ployees , of whom about 150 are professional officers. In practice the ad- ministration is ca rried on through various committees , primarily the executive committee and the staff and building committees . a The co mpulsory health insurance fund has to pay by law to the co unty co mmune according to the fo llowi ng schedule: 4 8 kronor fo r each o utpat ient physician visit (the patient himself pays 12 kron or) ; 20 kronor fo r each day of hosp italizat ion (the patient surrenders his "cash" sick ness benefits while hospitalized) ; half the charge for dental care o ther than preventive up to 1500 kronor , 25% of the charge exceeding 1500 kronor, 75% of the charge fo r preventive dental care (the remainder is paid by the patient himself and, for children aged 17-19 years, by the county commune); and , above certain mini- mum amounts, the cost of drugs, pharmaceutical supplies, and travel. Somewhat modified benefit s apply to home visits, telephone calls, and private consultations, as well as to stays in nursing ho mes and to convalesce nt care . In addition, the health insurance fund pays cash sums directly to persons eligible for maternity benefit and fo r re imbursement of in- co me lost during illness. 18 1 The Council committee most concerned with health services is the Health Care Board , which has local committees for the six health care districts.0 Fig. 4 shows the details. The health care department, the administrative secre- tariat of the Health Care Board, with its medical and dental care divisions (Fig. 5), is the most important service department. The principal officer of the health administration is the Director of Health Care. On the long-term (I 0-year) planning side, the responsible administrative group coordinates and supervises working groups in the following areas: emergency care; regional care planning (together with neighbouring county communes); primary care; ambulance services ; dental care; long-term care; psychiatric care; and medical support services. The emphasis is on the planning process rather than on the plan document itself, since implementation requires a great deal of cooperation and goodwill. The first draft of the plan for 1975 - 85 was drawn up by each planning group and discussed with trade unions, political parties, and othe r interest groups. The second draft was then merged with other programme plans, reviewed, and then submitted to the County Council in October I 976. Those parts of the plan proposal which were accepted by the County Council then be- came the official plan. The County Communeb has the responsibility for all health services, ex- cept for school, environmental, and occupational health care. The school health authorities usually have their own nursing staff, but employ county commune or private physicians on a contractual basis. A similar arrangement is under discussion for small firms. The total budget of the Commune in 1975 was 1828 million kronor, nearly 7% of which consisted of capital expenditure. Of this total budget health care accounted for about 80%. A resource inventory for all 6 health care districts together showed the following pattern in I 975: 19 primary care districts with 32 physician sta- tions (9 stations with I physician each, 13 stations with 2 physicians, 6 stations with 3 physicians, 3 stations with 4 physicians, and I station with 5 physicians); 77 district nurse stations; 26 maternal and 21 child care centres; and 3 dis- pensaries. There were 2 county hospitals, one with 850 beds (in Hlilsingborg), the other with 1690 beds (in Lund) , which also serves as regional hospital ; 3 district hospitals with an average of about 240 beds each; 2 mental hospitals with abo ut 1000 beds each; 9 nursing homes with an average of nearly 85 beds each (ranging from 24 to I 00 beds) plus 4 homes outside the jurisdiction of the County Commune; 7 homes for the mentally ill , with an average of 73 beds each (ranging from 63 to 84 beds); and geriatric clinics at all hospitals. There 0 Thl' County Council or Commune is divided into hea lth care districts. These health care dis trict s are further subdivided into small primary care districts, contiguous with primary communes in this county , where district physicians and nursing staff operate under the administrative supervision of the County Council . b The terms "Commune" and "Council", when referring to the co unty commu nal author ities, arc used interchangeably in the litera ture. 00 w Fig. 4. Malmohus County Council and administration COUNTY COUNCIL Executive Committee ,--- : Chancellery ,- - -I ________ I -- : Directora: --!- - -- -- - - :--~ -~ =- - - - - - ~ ~-----_r~~ ~~~ -----,:: :=~~-L -- --- -: !..-..-------- t---- 1 1 Planningand I , Data-processing 1 : 1 Finance : : Organization : : Department I ' I , . Department I I Department I , ____________ I I------- I 1 ________ _ I --------------7------ - - - - r - - - - - - ,- - - - - - - - - - - - - - - -. ____ .J ___ -- ----·----· I I I I : Personnel I : Salary : 1 Department : 1 Department 1 ~--- ~-----~-~ I Staff Committee ' ' 1 Health Care : I I I Department 1 ----1- Health Care Board ' ' _________ ..1 __ ---- : I • Directorates of the six I : I - - - - 1 - - - - I I - - - J _ - - - -I I Construction : 1 Purchasing i Department 1 : Department I I I - -- Construction and Purchasing Committee I - - - - ' - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -, .------1 _____ 1 ,-- - - ___ ..!.. ______ -, 1 _______ L ____ - __ 1 1 Social Care I I Vocational Rehabilitat ion : 1 Vocational Training 1 i Department : : Department 1 : Department i ,____ __ - - - - - --------' _____ ___ J Social Welfare Committee Vocational Training Committee ---0- Comminee structure : health care dis1ricts : I I - -- - - - - - rt---~-~------, Committees of the six health care districts ----c=J---- Administrative structure oo Fig . 5. Malmohus County Council health care department .j::,. l Long-term ( 10-year) planning unit I l I Planning section I l Short-term planning unit j Medica l care j division l Si x health care district organ izations j Di recto rate of health care Facility and equipment planning unit Secretari al unit I Common services section I l Information unit [ J Dental care J division J Legal unit J Other units were also 50 district polycljnics for dental care and 8 specialized dental clinics , as well as IO ambulance stations. There are also private practitioners , mainly in th e larger cities. One major concern is long-term care. About three-quarters of the chronically ill are more than 70 years of age. At present 62% of these old people are in institutions (homes for the chronically ill, psychiatric hospitals, hospital wards or sections for the chronically ill, homes for the aged, and priva te homes for the chronicalJy ill) ; about 36% are patients at home. Admission to these insti- tutions is authorized by hospital physicians. The homes for the aged are sponsored by the primary communes. The present most important need is to strengthen outpatient (primary) care vis-a-vis inpatient (closed, hospital) care. In 1975 the operating expendi- ture on hospital care was sti ll almost 6.5 times higher than that for outpatient care. Outpatient care capacity varied in 1973 in different districts between 17 and 44 physician-hours per I 00 inhabitants, with a mean of 3 1 hours. In I 973 there was an average of 6 I 2 I inhabitants to I primary care physician assisted by 2 .5 other staff. The main emphasis in present planning is on increasing the number and status of primary health centres and strengthening cooperation with the social welfare services of primary communes. It is felt that aU these services should be available under the same roof. FINANCIAL AND BUDGETARY PLANNING It has been earlier mentioned that the County Council establishes an annual budget, a 5-year budget plan, and a IO-year comprehensive health plan. The annual budget specifies the budge t for the first year of the 5-year budget plan and is used annually to help "roll" this plan forward by I year. The JO-year plan, on the other hand, is no t rolled forward each year but merely provides guidelines for the development of health care and a fore- cast of the income and expendit ure of the County Council. It is planned subsequent ly to make this forecast a rolling one so that it can serve as a frame- work for 5-year budget plans. Annual budgets have legal force, in contrast to the 5-year and I 0-year plans. The annual budge ts and the budget plans are originally proposed at the levels of individual health care institutions, the six health care districts, and the County Council. They are finalized after due consultations and adjustments between the various Council committees and levels. The financial and budgetary figures of 5-year plans are sent to the Federa- tion of Swedish County Councils. Here the plans of all the co unty councils are aggregated and the percentage of national income likely to be spent on health care is cal cu lated. The proposals for health care provision and health staff in the 5-year plans are submitted to the NBHW, which alJocates on a nationwide basis (a) con- struction funds for projects costing more than 500 000 kronor. and (b) new posts for physicians and dentists. 185 Regarding the 5-year plans, the Federation of Swedish County Coum:ils also feeds back forecasts on the national economy and information on the actual and predicted outcomes of nationwide negotiations with health staff. The Governor's Office provides mainly demographic estimates rather than economic forecasts for the county. From assumptions about future commune tax rates, which are at present restricted by agreement between the Govern- ment and the county communes, the County Council has to forecast its own likely income . There is some joint planning within the larger Sk~ne region, which includes Kristianstad County Commune. Its main purpose is to decide on how to share the operating cost of the regional hospital in Lund and of transfers of patients between counties. Each of the health care districts reports its budge tary expenditures every month, and every third month the figures are checked against the budget for the whole year. Actual or likely excesses immediately form the subject of discussions with the commune administration. Most expenditure is on hospital institutions and health care staff. As an example, the operating budget for 197 5 of a district (of which wages, including social benefits, amount to about 80%) may be broken down as follows: Hospital ( 160 acute and I 00 long-term care beds; 364 of 444 staff posts filled) ursing homes (at 3 locations ; 93 staff) Home for the mentally ill (3 0 staff) Primary medical care (in 4 districts and at 5 loca- tions; 3 3 staff) District nursing and midwifery ( 13 nursing sta- tions, I child health centre , I maternal health centre; 25 of 28 staff posts filled) Total for district (545 of 628 posts filled) Million kronor 34.4 6.3 2.2 4.2 2.1 49.2 At the present rate of county commune taxation there are several budgetary problems to be faced in the long term, such as the large utilization of care by old people . Only 2.5% of the population are over 80 years of age, but they consume 25% of the health budget; only I 0% of the population are over 70 years of age, but they consume 50% of the health budget. This also means less in- come, since taxes are only paid on 2 or more shared pensions. There are not at present enough places for long-term care, and there is pressure to provide at least I home for the elderly in each primary commune. To save costs more specialized laboratory services are centralized in 2 laboratories ; I laundry serves the entire Commune; and administration - and often catering - for all institu- tions is centralized at the district level. In order to economize on expenditure on care, the County Commune has initiated several pilot projects and studies, the re sults of which are utilized in the financial and budgetary planning. 186 The Malmohus County Commune has been among the pioneers in devel- oping budgeting systems over and above the ordinary system of line-item or control budgets. Districts usually have a budget which is itemized by insti- tutions and resource headings. One step that is being taken is performance budgeting by o rganizational unjts such as health care districts. Another step is in the direction of programme budgeting, i.e., budgeting by each major care programme. In the future both steps will be merged. The idea is that the budget should allocate resources to organizational uruts to carry out certain health care programmes. For the Trelleborg health care district ( the pilot area), the annual budget is not itemized by line items but is allocated as a lump sum for certain specified tasks or programmes. The aim of the pilot project here is to permit, in the man- agement of a total district budget, freedom of transfer between institutions and resource headings and to confer responsibility for carrying out detailed service object ives and tasks.0 The aim is to increase both management freedom and responsibility so as to improve the efficiency and quality of care. For the hospital, which accounts for nearly 7Wo of the operating budget of the Trelleborg district, standard costs have been calculated fo r each majo r type of service item (by ward, major diagnosis, patient characteristic, etc.). The trend of the present utilization pattern has then been forecast, thus leading to standard budgets for each ward and for the hospital as a whole . In these forecasts th e present utilization pattern of hospital care has not been questioned. How much of the work should be delegated to primary care services or nursing homes and how inpatient care itself could be in1proved in qual it y, such as by a fully graduated patient care system, remain matters for discussion. This standard costing will nevertheless contribute to greater economy- mindedness: it will allow comparison of the costs of treating certain cases in different wards and by different physicians; and it will help in the close moni- toring of actual changes in expenditure. The new budgeting concept has also been applied on a pilot basis to the programme for diseases of the locomotor organs, which in 1971 accounted for 15% of all inpatient cases. An analysis of the cost per patient episode showed only a relatively small variation between the health care districts. For a menis- cus (knee cartilage) injury , for example, the cost in 1971 varied from 2000 to 2600 kronor, the average cost being about 2250 kronor. A more detailed analy- sis of the care process, however, showed that this apparently minor variation was attr ibutab le to the fact that the districts with a low average length of inpatient stay for thjs condition (as low as 4.5 days) also had a high cost per patient-day (exclusive of X-rays, surgery, and anaesthetics), while the districts with a high average length of stay (as high as 9 days) had a low cost per patient- day . The former, however, cost less on the whole than the latter. It was further found that orthopaedic surgeons discharged their patients much earlier than general surgeons. Since o rthopaedic surgeons were mainly concentrated in 0 By co ntrast. there is no freedom to carry over funds from o ne year to another ex- cept in the case or the capital budget, where the no n-use of funds is . however. said to be a rare occurrc nee . 187 Lund, the district with the shortest length of stay, this distric t had to care for a larger number of patients than could be expec ted on th e basis of its popula- tion. Therefore, on the basis of this analysis , one orthopaedic department in Lund was closed since there was no evidence of economies of scale, and the orthopaedic surgeons released were placed in other districts. This has already led to considerable cost savings. There are studies that aim, rather than at justifying new and additional resources, at reducing the length of stay and at a more efficient use of exist- ing resources without lowering the quality of care. Such studies are often initiated in the commune and co-sponsored by the SPRI. A project in the health care district of Ha lsingborg, for example, is now searching for an or- ganizational so lution to reduce the average length of hospitalization for frac- ture of the neck of the femur. The time at present ranges from about 22 days in the Lund district to about 73 days in the Landskrona district. The aim of the pilot project is to organize active rehabilitation , including assistance for the mental adjustment of patients , by making better use of physiotherapists and other staff. With such reorganization it is thought feasible to cut the average length of hospital stay to 17 days. Similar action studies are planned for ear conditions, for diabetes , and for breast cancer , in that order. New treatment programmes have usually been pioneered in Lund, and it has now to be shown by proper organizational innovation in other districts that care costs can be reduced while the quality of care can be improved or at least maintained. Reference was also made to an SPRI study on economies of scale in acute hospitals. It was shown that very small and very large hosp itals were very ex- pensive per hospital bed, while the lowest costs we re incurred in hospitals with 300-400 beds. These medium-sized hospitals were viable units and had, therefore , also attracted good hospital administrators. Such a U-shaped cost curve (where unit costs are plotted against the number of beds) was also con- firmed to exist for the supportive systems (usually regarded as "overhead") in hospitals. Research has centred mainly on hospital inpatient care;only now are pilot studies being conducted on the utilization of primary care. But research is still needed on questions such as: "What are the effects o n overall health care ef- fectiveness and cost when more money is spent on home care or nursing homes?" or "Can a better health ca re system pay its way from th e point of view of the overall economy?". Another area for future research concerns th e practical- ity of a more aggressive approach to preventive medicine, with intervention in environmental factors and personal habits whenever th ey create health risks. The annual congress of the Federation of Swedish County Councils, in 1975, stressed th e need to go beyond medical care and to intervene actively in the fields of alcohol and tobacco consumption, driving habits , and other sectors of social life , in order to red uce the need for health and medical ca re and thereby reduce costs . There is little interest in health care studies in the unive rsity , rather the reverse . Thus the university has tried to persuade the Commune administration to continue st udi es and to take ove r research eq uipment (such as mini-computers) in which th e university is no longer interested. 188 In the future, once an information system is developed that follows both the population and the patient, cost-effec tiveness and other stud ies will be in- stituted to achieve better programming of health care as a whole. Such an infor- mation system might also induce the social security funds to carry out cost- benefit studies of alternative health care approaches and enable them to conduct more efficient negotiations for funds with other economic sectors. LONG-TERM PLANNING OF ACUTE HOSPITAL CARE The chief physician of each clinic a is asked about the present situation and the plans for the next decade. He prepares a protocol for his clinic. The proto- cols also include the views and plans of the chief nurses, who often function as managing directors. These protocols are then discussed with a group consisting of chief physicians, chief nurses, and other senior health professionals and re- vised. The groups nominate I representative each (about 106 persons for the entire County Commune) to I or more Commune conferences on the planning of acute hospital care in order to reach a further broad consensus. Thus far patients have been involved only in the planning of emergency care, but they will be consulted in the future through representatives of pa- tient associations and also through direct surveys . It is a typical Swedish feature that associations of health care workers are represented throughout the planning process, both within the clinic groups and within the steering group for all the long-term health planning of the Commune. The County Commune prepares its plans on the basis of frequency of procedures rather than of categories of specialties. This assumes that frequent ly required procedures , especially those of a routine nature, are provided in dis- trict hospitals , while less frequently required procedures are provided in county hospitals and the least common or most specialized in regional hospitals . Another principle is the separation of short-term and long-term care. At present about 25% of acute beds in medical clinics are used for long-term care. If long-term care facilities can be developed, such beds could be freed for acute ca re. On this basis it is planned to stabilize the number of 2500 acute beds un- til at least 1980, which would in effect reduce the number of acute beds per JO 000 inhabitants from 53 to 43 in I 980. A unique feature of health planning in this particular coun ty comm une is that the planning groups of the Commune administration include clinical phy- sicians working in planning on a full-time basis. In almost all other county a A clinic, in the Swed ish sense of the word, is made up of one or more hospital departmen ts. Clinics and departments arc headed by chi efs, those of the departments being adm inistrative ly responsible to those of the clinics. Both arc subo rdinate to t he medical director of the hospital, who has both administrative and clinical duties. The chief nurse of the hospital has the standing of a head of clini c . There is also a full -time admin- istrator responsib le for genera l hospital management. 189 communes the physician input is provided by the SPRJ on a short-term basis. A continuous physician input has made for easier communjcation with prac- tising physicians and places more emphasis on the planning process as a means of continuing education and learning. A shortage of hospital physicians is not foreseen in the future. On the con- trary , the NBHW may be providing too many training places. At present the demand for specialist posts exceeds the supply, mainly because of a recent national law that requires assistant physicians to take up specialist posts in the hospital sector after specialization. There is , however , a shortage of hospital nurses in spite of increased training capacity in the County Commune, mainly because of the high turnover and wastage rates among nurses.0 LONG-TERM PLANNlNG or DENTAL CA RE Long-term planning in dental care is at present carried out by an ad hoc working gro up. Once the present long-term plan is finalized, the organization of planning in this field will be permanent. Six subgroups of dentists as well as den ta! workers and technicians have, within I year, produced progranm1es that have now to be integrated into a plan. The County Commune employ s about half of the dentists . The proportion of dentists in private practice (now about half) can be expected to decrease, since a new private practice can only be established when an existing one becomes vacant. In addition , the income differential between roughly 70 000 kronor (for public dentists) and 90 000 kronor (for private dentists) is not very large if it is taken into account that the public dentist does not bear the cost of establishing, equipping, and staffing his pract ice . There is no problem about the geographical distribution of the 195 dentists and dental specialists in the count y. Public dentists are paid on a capitation basis for children up to and in- cluding 16 yea rs of age, and on a fee basis for the rest of the population. The County Commune is responsible fo r providing dental care for children up to and including 16 yea rs of age ; it is free of charge to the ch ildren in public dental clinics. The rest of the population can also utilize th e public clinics, but on ly for an initial visit and recaUs sched uled at intervals of about 15 months. They pay a part of the charges themselves , while social insurance funds pay the remainder. The County Commune has recently assumed responsibility for the out-of-pocket expenses of children aged 17 , 18, and 19 years. The out-of-pocket share is quite low (25% of the total charge) for preventive den- tal care so as to encourage a positive approach to dental health and regular a A ftcr grad uating from high schoo l when they arc 15- 18 years old , gir ls (and , more rarely. boy s) arc trained in a district hosp ital for 2 years as nursing aides. The training of nurses is provided within the County Commune o nly in Lund or Malm o. The period of tra ining is 2½ years, plus 6 months for specialization (part of which can again be provided within a district hospital) . 190 screening. It appears that public dentists are becoming dissatisfied with the administrative burden these multiple sources of and claims for reimburse- ment are imposin g upon them. In 1974 the public dentists spent abo ut 58% of their time on children up to 17 years of age. However, since children's appointments take up less time (o n average 95 minutes per child as against 128 minutes per adult), about 65% of their patients were less than 17 yea rs old. The dental care programme in 1975 , after reimbursement by the social insurance system (about 15 million kronor) and out-of-pocket payments by the po pulation, cost the Commune administration about 30 million kronor. Fluoridation of water is not feasible, since existing laws do not permit it. The e mphasis is therefo re on other preventive efforts, namely on the se lf- administration of nuoride in toothpaste but mo re especially on professional flu oride "treatment" o f teeth. Taking treatment also into account , planning is based on the assump- tion that al l child re n of less than 3 years of age require an average of 20 min- utes of consultation per year, 95% of 3 - 5-year o lds requ ire I hour, 95% of children from 6 to 16 yea rs and 90% of 17-19-year olds require 2 hours, and on ly 20% of the 20-year olds and older people (because of private prac- tice availability) require 2 hours. To achieve this high coverage with more preventive treatment at an acceptable cost, there will have to be a greater emphasis on dental paraprofessionals and auxiliaries. On average, a dentist (including the category of dental specialist) now has 1.7 co-workers (other than clerks), namely dental technicians, hygienists , nurses , and nurse aides.0 It is planned to increase this ratio to 3.2 co-workers per dentist. Therefore, while it is planned to increase the number of dentists by 34% to 261, the in creases are 150% for dental technicians, over 188% for dental hygienists (to 11 9), and 12 1% for dental nurses (to 572) and nurse aides (to 81). It is further planned to place specia l emphasis on the care of the I 0% of children who are at a high risk of deve lo ping caries, by having them recal led every 2 months for cleaning and nuo rid e treatment. There has also been an attemp t at standardizing a multitude of den- tal ca re procedures that can be and have been applied successfully in prac- tice. The ease with which standard ization can be achieved in dental care as compared to medical care is attribu table to the fact that the wo rk is re la- tively more ro utine. a The training of dental nurses consists of I yea r of special co urses . They arc a llowed to po li sh teeth but they cannot, unlike de ntal hyi:icnists, remove hard surfaces. Th e latter are de nta l nurses who have been trained for a further year after 3 yearsofprac ticeasdental nurses. remale paramedica ls can wo rk part-time and there is no "drop-out" problem , in contra st to fema le med ica l care nurses, whose wastage rate is 35%. 19 1 LONG-TERM PLANNING OF IIEALTI-I INFORMATION SYSTEMS The information group in the medical care division of the health care secre- tariat compiles and retrieves data. It is closely linked with the data-processing department of the County Commune. Most of the present data refer to inpatient care. In one project the waiting lists for admission to various departments are being analysed according to pre- liminary diagnosis . A second project is the recording of inpatient episodes, in- cludin g a calculation of average lengths of stay. A third project deals with the fmancial implications of inpatient care, including claims on the social security office. A fourth project concerns the use of !CD codes for diagnosis, surgery, and anaesthesia. In addition there are various projects on routine administrative and medical information. Reports are not produced automatically but on ly at the request of the users, i.e., the physicans, administrators, and econom.ists. Statistics are sent annually to the NBHW. Information on outpatient care is still weak. A model information system similar to that for the inpatient system has now been developed, partially utilizing the Dalby health care consumption study (see pages 195- 196). It is planned to be implemented in 17- 19 hospital departments and health centres, later it will be introduced into all hospital departments and health centres. This proposed system excludes telephone consultations and district nursing visits since the additional administrative work entailed would be too great a burden on the nurse. Much thought is now being given to the automation of the proposed in- formation system over the next 3-8 years. Basically it is to be only a more technically sophisticated and more standardized version of the existing system. A central computer in Lund and 12 clinical terminals are already in existence. Confidentiality is ensured by means of coded keys. One possible solution for the planned inpatient system could be as follows. The patient arrives at the hospital where he or she is registered in the ward ter- minal through a card showing the personal number. The information is passed to the central computer via the hospital's minicomputer. The central computer then transmits back the patient's medical history, to which the clinic can add its own case information to arrive at its own patient reco rd . Wh en the particular episode ends part of the data are destroyed and only the most relevant infor- mation is sent to the central computer for addition to th e patient's record. It is obviously not feasible to equip each health centre and other primary care stations with a computer terminal for outpatient records. Moreover, pri- mary care providers prefer to write and store their own records . Requests for information by district physicians and others will have to be made by tele- phone and the print-out se nt by mail or car. In the future thought may also be given to an automated research system for the purpose of health planning and evaluation. This would mean that part of the clinical data of epidemiological and economic relevance otherwise des- troyed (i .e., not used in patients' histories) would be stored in a separate sec- tion of the main co mputer for further analysis. Such information wou ld link 192 episodes of ca re with resource inputs and the cos t-effectiveness of care could be evaluated. This information is of grea l use to planners, but until providers of care themselves find ii usefu l no decision in favour of these more costly out - patient and research systems can be made . THL DALBY PRIMARY CA RE DISTRICT The Dalby primary care district acts as a pilot area in primary care for the entire Malmohus County Commune. II is a part of the Lund primary care district, which is I of 6 primary care districts in the Lund health care district. Six ge neral practitioners (district physicians) work in I health centre and make services available to 18 000 people. Waiting lists vary seasonally, but at prese nt there is only a list for foUow-up visits for non-emerge ncy patients and the waiting period for them is 2-3 working days . If the waiting list is allowed to become too long patients do no t make appointments but come directly to the health cent re as emerge ncy cases. One of the major factors in the short waiting time in the Dalby health centre is that a nurse acts as the appointment officer, with instructions to be generous in favour of patients. A second factor is the discipline of the patients themselves. An investiga tion of self-declared emergency cases in the whole of th e Lund health care district in February I 975 showed that only I 0% were not true emergency cases, while about a half required immediate attention and about a quarter required att ention within 24 hours . Other factors are involved , such as active follow up , care provided by nurses on their own initiative , and collabora- tion with the social welfare services. Over the 3 years from the opening of the Dalby centre in 1968 visits to heal th centre increased by 45%, while visits to hospital outpatient depart men ts by residents of the Dalby district increased by only I 0%. There were no rel- evant changes in staffing over this 3-year period . One of the physicians has a half-time clinical and administrative appoint- ment as head of the centre, and he spends the o ther half of his working time on research . The day-to-day management of the centre is the responsibility of an administrative nurse. Two of the physicians concentrate on emergency care (especially after regular working hours) and on home visits (where the demand still exceeds the supply) . This round-the-clock service is provided on a pilot basis and is judged to be successful.0 0 In the o ther areas of tile County Commune there is one primary care centre in each health ca re distri c t for emerge ncy calls up to midnight only o utside the o rdinary work ing hours (8 a.m. to 5 p.rn . from Monday to Friday inclusive). After midnight the onl y e merge ncy ca lls arc to the hosp ita ls . During th e work ing hours nurse sta tion s. pri- mary physician offices, and hosp it a ls share in emergency care. Emerge ncy transport is by both ta xi and ambulance. 193 The district nurses 0 (2 or whom arc attached to the health centre while 4 have offices elsewhere). J~sistcd by 5 nursing aides, make home visits in- dependently or physicians. The midwire (attached to the centre) supervises pregnancies on her Pwn (except ror 3 visits by the physician during a preg- nancy and 1 visit aft er delivery) and gives family planning advice, including the prescription of contraceptive pills, the insertion or intrauterine devices, and counselling on abort ion ( free on demand by mothers). One district nurse cares for diabetics, the nhysician being involved on ly once annual ly in most cases. Similar care, mai11ly the responsibility or nurses, is now provided on a pilot basis for hypertensive and psychiatric patients also. It is planned to make physiotherapists responsible for the active care of rheumatic cases ; at present there is only I physiotherapist , assisted by trainees. In general, pa11ents requiring continuing care are referred to district nurses directly, both by district physicians and, increasingly, by hospital physicians. This delegation 01 tasks and responsibilities to nursing staff has had excellent results. The delegation is also economically _justified, since district physicians are no longer pai d according to the number or patients they see but are now salaried staff. The main task of the district nurses is preventive child care, including school health care (on u contractual basis with primary communes), especially where smaller schools ca1111ot afford their own school health nurse. The physician visits the child health centres, which are run by district nurses for children up to school age , once a week to give vaccinations. Since 1958 a special health control has been in operation for the 4-year olds. in order to detect hidden mental defects, impairment or sight and hearing, etc. This control is gradual ly being expanded to cover all preschool chi ldren . A recent national law makes primary communes responsible for the cost or providing special schools. homes, etc ., for children with particular needs. Primary health care providers are responsible for health care on ly at such specia l institutions. On the other hand, child welfare requires the close co- operation of primary health care and social we lfare workers. A study showed that the social and economic problems of parents, mainly young working parents, are closely related to childhood diseases, and that problem children are first detected by social workers and later by nurses, coming finally as patients to the physicians. After about a year 's discussion it was therefore decided to include social workers in the health centre and this has been done since Jan- uary 1975. This experiment or integrating social welfare with primary health services exists m on ly a few other places in Sweden. Malmohus County Com- mune is especially for tunate also in that its primary care districts f"it in with the boundaries of the primary communes. a It is usual in most areas in Sweden for nurses, physicians. midwives.and other health personnel to work independently ot one another. except for some clinical supervision b} physicians. In Dalby the work is coordinCJt<:d ancl carried out more on a team basis. -.-ith social workers also included. Alth ough a senior physician earns abou1 150 000 kronor per year and a fully quaJifiecl nurse abou t 50 000 kronor, the differen,T is considerably narrowed after taxes are deducted because the la>- system is highly pru!!ressive . 194 The social workers , whose main task is home visiting, now have a strong working re lat ionship with district nurses . They have regular - at least month- ly - joint meetings, whjch are sometimes attended by physicians as well . The study of problem families and chi ldren described earlier was based on an ex- change of records and experience and has led the nurses and social workers to think in terms of epidemiological or health-risk factors ; problems can now be better anticipated and solutions planned accordingly. Already the primary commune in wruch Dalby is centred has decided, on the basis of this study, to build certain special day homes and schools. In the primary care district there are no big industries but there are several smaU ones. Th e on ly link between the centre and occupational health services is provided by one of the district physicians, who serves some of the industries on a subcontractual basis. There is almost no cooperation with the authorities responsible for environmental health, i.e., the primary commune administra- tions and the regional medical officer. The main principle of primary care is to prevent, diagnose, and treat as far as is possible at the primary level and to refer cases as little as possible. The centre has no X-ray facilities and has therefore to send people to Lund for radiological investigation. Hospital physicians do not at present go to the health centre. The establishment of consultant sessions, particularly with general surgeons , is now under discussion. In Sweden little reliance is placed on mass screening. The hospitals provide screening for cervica l cancer for all women between certain ages , but only 60% of them, not always those at high risk, are motivated to participate. There are often neurotic and unjustified reactions by patients to screening results. Evalu - ation of screening results is difficult because environmental factors and per- sonal habits are not included. The Dalby centre, however, performs some screening as part of its research work, which has been part of its operation since its inception in 1968. The re- search includes: a study of pensioners born in 1902 or 1903, who are examined eve ry 2 years for dental, psychiatric, social, and economic problems; an analy- sis of the food consumed daily by old people and diabetics ; and a study on the distribution of the cost of becoming ill. The importance of these research activ- ities can be seen when the annual expenditure of2 000000 kronor for research is compared with that of 1 500 000 kronor for primary care services. Research is by no means at the expense of the quality of primary care activities. Another research activity of immediate use to the long-term planning of primary care by the County Conunune relates to the delivery of primary care itse lf. The Dalby centre has contributed the data from its pilot information system to th e consumption study discussed below . LONG -TERM PLANNING or PRIMARY HEALTH CARE The ana lysis for Dalby for 1973- 74 showed that the average person made about 2 outpatient medical visits per year (excluding telephone caJJs and 195 laboratory and X-ray tests), and another 2 visits for preventive and promotive health care (mainly nursing care and midwifery).0 Of the outpatient visits hos- pital departments (with about 75 physicians working part-time on outpatient care) accounted for 50%, the health centre (with 5 full-time physicians) for 42%, and private physicians in Lund and elsewhere (9 fulJ-time and 6 part- time) for 8%.h The duration of an average visit to hospital was 15 minutes, while Dalby centre doctors spent 20-30 minutes with a patient. An analysis of the outpatient visits by diagnosis shows the fol)owing pat- tern: most visits were for acute infection of the upper respiratory tract and in- fluenza (190 visits per 1000 inhabitants), for fractures and injuries (142 per I 000 inhabitants), and for inflammation of the ear ( 127 per IO00), while mental illness occupied thirteenth place (46 per IO00). Ninety-three per cent of the population knew where to go for advice, and most emergency service utilization was justified. Forty-four per cent of the population had no physician visits during the study year, but about 80% of those who lived in the district during both 1969 and 1973-74 had at least 1 visit during either 1969 or 1973-74. One-third of the population had visited the health centre. Patients' dissatisfaction was mainly about waiting time (especiaUy for emergency care) and lack of information, indicating the need for the district physicians to spend more time on each visit. The health centre had referred about 5% of patients. An investigation of hospital outpatient departments (including interviews with clinic chiefs) showed that at least 20% of all visits there could have been dea lt with at the health centre.c Diabetes, hypertension , and asthma cases alone took up about 50% of the outpatient capacity of medical departments. Not surprisingly, the medical outpatient departments of hospitals had a waiting list of 6 weeks. Another source of information on morbidity episodes was the absenteeism records of the social security office; 73% of all absenteeism claims are self- certified.d An analysis of these claims shows that 40% of the average popula- tion between 16 and 65 years of age claimed to be sick during the study year. Colds, influenza, and other respiratory infections accounted for more than one-half of the self-diagnosed cases. The long-term planning of primary health care takes the Dalby figure of about 2 outpatient visits (plus 2 preventive health visits) per resident per year and adds 0.5 to obtain the target for the County Commune as a whole by 1985. 0 The average number of visits per year varied of course by age group. For example. for medical outpatient care it varied from 1.6 visits per person aged I 0-19 years lo 2.7 an- nual visits per person aged 60 years and over. b In the County Commune as a whole. visits lo private physicians amounted to about one-quarter of the 1.3 million outpatient visits 111 1974. c The figures were 52% for medical visits , 16% for paediatric, 15% for surgery. 13% for orthopaedic, 38% for urology , 21 'if for obst etric, and I 2% for psychiatric specialties. d In the Swedish system a simple call 10 the insurance office asserting sickness (and stating the reason) suffices for staying at home for a maximum of 7 days on that ce rtifi ca- tion alone and for co llecting sickness benefit (for the first day from the employer, and then from the socia l insurance office). 196 Taking into account how much of the hospital outpatient workload could be shifted to primary care, the target for outpatient visits per individual per year is 1.5 visits for primary care and 1.0 visits for hospital outpatient care (ex- cluding telephone consultations). This target calls for a doubling of the number of district physicians and their organization in health centres similar to the Dalby centre. In addition, it is planned to provide chronic care in each primary care district in homes of 60-80 beds, each home to be closely linked with a health" centre. The physician-nurse teams, the health and social welfare collab- oration, and the telephone system of appointments and medical advice by nurses that have been pioneered in the Dalby centre are to be introduced in other primary care districts. They will, however, unlike the Dalby centre, carry out only a little research on primary care . LONG-TERM PLANNING or, LONG-TERM AND INSTITUTIONAL CARE The working group engaged in planning the long-term and institutional care programme includes, along with County Commune officers, 2 social workers and a social welfare administrator from the primary conununes, a superintendent of a care institution, 5 physicians, and 2 district nurses. The group meets every 4-8 weeks to prepare a draft plan. Agreement has been reached on the main lines of the programme plan and they are now incor- porated in the 5-year budget. Many acute hospital beds are now occupied by chronic patients because there is a shortage of chronic hospital beds. At the same tin1e, half of the pa- tients who applied for long-term care could be cared for in homes or at home. It is therefore proposed to phase out special long-term wards in acute hospi- tals and to reserve a total of 5% of beds for chronic care in each acute hospital ward. Care in the patients ' homes has to be strengthened as well, and this re- quires more district physiotherapists and better assistance (e.g., for cooking) from the social welfare authorities. More patients with senile dementia can be moved from psychiatric hospitals to special sections of homes for the elderly only if more of these homes are established. The proposal calls for long-term care permitting the patients to live a nor- mal life within the community. This involves a better relationship between patients and care staff and a wider use of integrated teamwork. The target is to have I nursing home in each primary commune and several institutions in bigger cities each accommodating about 60 people, since otherwise they be- come expensive and unwieldy. A better working relationship between primary care and social welfare services is now under discussion between the County Commune and the pri- mary communes. Responsibility for the integration of both services, as in Dalby, could then be transferred from hospital physicians to district phy- sicians, while some hospital physicians ( of whom there is expected to be a surplus in the 1980s) could be given responsibility for care in the local homes. 197 LONG-TERM PLANNING OF PSYCHIATRIC CARE The planning group for psychiatric care has had a head start on the planning groups for acute care, since considerable interest has been shown in this field by County Council members . Subgroups work on psychiatric specialist care , the problem of drug and alcohol addiction, the rehabilitation of psychiatric cases, and pilot projects on psychiatry in general hospitals and primary care. Since quantitative evaluation of psychiatric care is more difficult than in general medicine , planning is based more on principles and est imation. Its planning group therefore involves community leaders, past and present patients, the six patient associations in the County Commune, and the social welfare authorities. The County Commune is responsible for all psychiatric care. There are 2 large psychiatric hospitals, one in Hiilsingborg (with 900 patient beds) for the northern part of the County Commune, and one in Lund (with I 000 patient beds) for the southern part. The Lund psychiatric hospital also has a section for the criminally insane, who are committed by the State. These hospitals were not unlike prison camps when the State trans- ferred them in 1967 to the County Commune, and they have since been partly reconstructed. The County Commune also has 7 special homes for the mentally ill. In addition , the County Commune, within its social care programme, provides sheltered workshops and subsidizes organizations for the mentally handicapped. It is proposed to include a small psychiatric department of 10 beds (including 4-5 beds for detoxication) in general hospitals and to strengthen outpa tient and primary care. The primary care units would not have spe- cialists in psychiatry but instead a nurse who has specialized in psychiatry. These nurses would also make home visits. This arrangement has already proved feasible in the Dalby centre and in the Landskrona district. A north- ern and a southern team in the County Commune, each consisting of psy- chiatrists, psychologists, social workers, and psychiatric nurses, will super- vise all psychiatric care and act as consu ltants. This emphasis on outpatient care and general hospitals will allow a decrease in the number of inpatient beds to 500. There is already supris ingly good cooperation with social welfare ser- vices, especially for drug and alcohol addicts. Severe cases are dealt with in the detoxication units of the psychiatric hospitals (I 8 beds in the south and 12 beds in the north of the Commune), while a team consisting of a physician , 2 social workers , and 3 specially trained psychiatric nurses fol- lows up addicts at home and in rehabilitation. It should also be noted that there is a lively exchange of views regard ing the relative merits of psycho- therapy and drug therapy. There is ge neral agreement that the mentally handi- capped should live in small community homes. One recurrent problem is that of the availability of nurses for psychiatric care. This problem is especially acute in the summer. 198 COMMENTS The average Swede is less likely to die in infancy and more likely to reach the age of 80 than most average people elsewhere in Europe. How far this impressive health achievement can be credited to the health service sector and how far to advanced economic development and social cohesion remains a matter for deeper analysis. In spite of, and in part because of, this very achievement, the development of the health and medical care system may now have reached a critical point in the eyes of consumers and there- fore also of politicians. The cost of the service is quite high, whether calculated per head of population or in terms of national income. Demographic changes, especially the aging of the population, and epidemiological changes, especially the trend towards an increase in chronic degenerative disorders, can be expected to in- crease the demand for health and medical care. On the other hand, the general population has become increasingly averse to paying a larger share for health services, especially in relation to the income taxes they pay to county com- munes. Already the three taxing authorities, the State, the county communes, and the municipalities, have had to agree on a joint income tax ceiling for the years ahead. Additional gains - a yet lower infant mortality and a yet longer life expectancy - are difficult to achieve. In the present state of health tech- nology and with the present cost constraints, they would appear to call for more centralized, equipment-intensive, care. Perinatal mortality, for example, could probably be reduced still further if all deliveries were to take place in county hospitals where the whole battery of diagnostic and life-saving equip- ment is available.0 The general population, however, is becoming increasingly opposed to big and relatively impersonal institutions and prefers care that is easily available at home, at school, and at work, and that places little cost burden on the consumer. Given this imminent clash between consumers and those responsible for the provision of care, it is no coincidence that major health planning efforts are now being made. Health planning is not new to Sweden, but the present efforts are more comprehensive and involve more people than previously. The 3 county communes and boroughs of the Skane region, namely Kristian- stad, Malmi:ihus, and the city of Malmo, had, for example , drawn up a joint health plan from 1967 to 1970 that was never implemented. The planners, who were mainly health administrators and scientists, were not concerned with planning as a learning experience and made little attempt to exchange information and experience with others outside their own group. The main responsibility for health planning within the framework of na- tional laws, guidelines, and priorities falls on the county commune. The various a Interestingly enough, 400-500 "taxi deliveries", in which the women were not under special care for possible obstetrical complications, were perfectly normal. 199 health planning groups in the Malmohus County Commune work at present on an ad hoc basis and include as needed various disciplines other than medi- cine and administration such as epidemiology and economics. It will not be an easy task to combine the various separate programme plans in to a compre- hensive IO-year plan. It may take much time to agree on clear priorities. At the same time , there are an increasing number of constraints on plans, in- cluding nationally negotiated wages and salaries, laws protecting employment security (making it more difficult to transfer or fire staff once hired), and rationing of investment (especially construction) funds and of physician posts. It is hoped therefore that these interdisciplinary planning groups will become part of a more permanent planning structure. Only then will it be possible to monitor , evaluate, and further develop pioneering serv ices such as integrated health and social care in health centres, as well as pilot sup portive efforts such as a comprehensive information system for primary care and a programmed approach to budgeting in health care districts. These experiments require many research man-years which, according to the Cou nty Commune administrators , will not be availab le in the future. Thought should therefore be given to utilizing the most relevant findings in establishing routine information and administrative systems. This in turn re- quires a reorientation of the councillors and administrators of health care districts, who still often think of their districts as "hospital districts" in spite of the new emphasis on primary care and ge riatric nursin g. Thought should also be given to increasing the number of primary care districts in cities, since the present situation derives from the past , when outpatient care was almost exclusively provided by hospitals and private physicians. The delegation of many community care tasks to nurses and midwives in the Dalby district has in1proved the continuity of primary care without loss of quality. This should also be possible in the other primary care districts. The problem that may arise in the future is that th e skills of the primary care physicians in carrying out such tasks may atrophy unless the nurses continually keep them abreast of performance. Other very striking factors are the relative lack of primary physician care in Sweden as a whole and the lack of coordination between doctors, nurses, and midwives. The teamwork now being developed in Dalby highlights the need to strengthen health services at the primary level. The NBHW has been instrumental in developing and monitoring national gu idelines in the health field and in providing a more equitab le distribution of care among different geographical areas . Its ro le in regulation is mainly nega tive, i.e ., it can ration key manpower posts and investment funds only in so far as they are proposed by county communes. It is, however, likely that there will be a surplus o f physicians in the next decade and that the degree of control by the NBHW will consequently be diminished. On the other hand , the NBHW could play a more important role in inter- sectoral planning for health . At present personal, occupational, and school health services and social welfare services are separate programmes without proper overall gu idance and coordination. The dual system of commune and occupationa l health care, for example, makes for high costs, is inequitable for those taxpayers who pay taxes for occupational health services without being ab le to use them , and provides an opportunity for workers to jump the queue 200 for the outpatient care provided by county communes. The county communes could play a role in providing a pool of resources for care for the many small rural industries, such as I physician (full-time equivalent) per 2000-3000 em- ployees. Pilot studies, for example in the primary care district of Dalby , could serve to determine more precisely the specific needs of such small rural in- dustries and to suggest practical organizational solutions for integrating occupa- tional health care with general primary health care. Primary care also includes environmental health, school health, and social welfare services. Most of these, however, are the task of the primary communes. In spite of the fact that the boundaries of primary health care districts often coin- cide with those of municipalities, primary care is not generally integrated. Several pilot projects , such as the Dalby health centre, have now demon- strated the feasibility of a closer working relationship in social welfare and school health between primary care providers in the health districts and the primary communes. The development of such primary care linkages at the operational level calls for a correspondingly broader perspective in national health planning. This broader perspective would have to include the anticipa- tion and reduction of health hazards in the environment and in personal be- haviour, and therefore the stimulation of appropriate action in other sectors of the economy. A closer relationship must therefo re be developed with en- vironmental health care, work safety, and indeed mos t socioeconomic fields. In tersectoral health planning across all sectors of health care is also re- quired at the county level if there is to be effective planning. The main agent of the NBHW at the county level is the regional medical officer. At present he is mainly occupied with routine supervision of environmental health affairs and epidemics and has little scope for participating in the health planning of the county commune. In this he resembles public health officers in Austria or the Federal Republic of Germany. It may in the future be worth while to consider a reversal of his functions: most of his supervisory functi o ns would be taken over by the county commune authorities while his main role would become that of a health planning adviser, especially as regards in tersectoral affairs. The self-governing county communes will in the future have to accept additional responsibilities such as for public transport and communications and for cultural affairs, which in turn will provide a better basis for the overall regional planning of socioeconomic affairs. This is an interesting situation, the growth of the county council's responsibility taking place at the same time as an apparent reduction in the responsibility of the Governor's Office and the regional medical officer, and it may take time to settle down. With more emphasis on decentralization, questions of authority between primary and secondary communes may also arise. At present the movement appears to favour the county councils. However, whether they have the capability to as- sume responsibilities now in the hands of others may be questioned. The national research institute of the SPRI has given valuable assistance to the county communes, especially by cosponsoring a large part of their health planning research and by developing technical guidelines for health planning. In addition, the SPRI has promoted research to standardize a number of thera- peutic procedures. The standardized procedures need to be further developed 201 and tried out in organizational settings to test whether they are cost-effective and acceptab le to health care providers and consumers . It is desirable that the SPRI should also conduct research into the advantages and disadvan- tages of the various health planning processes that take place in different county communes , so going beyond the formulation of technical guide- lines for planning. Imaginative studies utilizing the research capacities of universities are also needed o n ways of controlling service costs. A better information system on outpatient care and a more strategic use of economics and operational research are both required for this purpose. As a wealthy country, Sweden is in a unique position to develop in forma ti on systems that describe the primary care con- tacts of the population, its utilization of therapeutic and rehabilitative care, and the economic implications of its diseases and disabilities. The findings of cost-effectiveness and cost-benefit studies can then be applied to improve the programming of health care and other health-related activities and provide a better position for bargaining vis-a-vis other sectors of the economy. Some approaches will, of course, generate cost savings only in the long run and may even cost more in the short term. There is, for example, greater scope for telecommunication in primary care than exists at present, particu- larly as health centres with 4-6 physicians as team managers are developed. An automated priniary care information system would also be of great bene- fit in bridging the cap between the very centralized system of health care advocated on technological grounds and the decentralized system desirable from the point of view of the consumers ' convenience. Patients, for exan1ple, could be X-rayed at a health cen tre linked by telecommunication with a hospital. Pharmacies and toxicology centres could advise on drug therapy. Pat ient records could be retrieved speedily when people moved or asked for prescriptions over the phone. Action to control costs will also require an input of economists and operational research workers in health planning and evaluation at all leve ls. Nobody knows at present, for example, whether proposed health care develop- ments wil l add to or reduce the economic burden of ill health on the overall economy. At the same time, there is no evaluation of whether the distribution of the total burden is equitable between the population groups that ultimately bear the burden of paying for health care, the groups that are best able to pay, and the groups that receive the major economic benefits from the provision of care. This poses the question whether there is a need for university or inservice training of health economists and operational research specialists in order to eva luate th e system. 202 VIII DENMARK J.E. Asva/11 & H.F.K. Zo"llner2 Denmark is one of the smallest countries in Europe, with an area of only 43 000 km2 . It consists mainly of the peninsula of Jutland and the islands of Funen and Zealand. The Faroe Islands and Greenland also form part of the kingdom but since these are located far from the remainder of Denmark and possess quite different characteristics, they have been excluded from this study. The population numbers approximately 5 000000,and the rate of growth is only 0.6% per year. The population density is fairly high - 117 persons per km2 . The land is relatively flat; communications in general are good and travelling distances are shorter than in most European countries. Of the 4 000 000 people who live in cities and suburbs, 2 000 000 are located in Copenhagen and the other towns of Zealand. No political party has achieved an absolute majority in recent years, so that Denmark has had a series of minority governments. A major field of cooperation between the Governmen t and the Parlia- ment is the formulation of new laws. Each bill is initially debated generally in Parliament, after which it is passed on to the important 17-member commit- tee whose members reflect the general distribution of representatives among the political parties of the Parliament. These committee meetings are not pub- lic. The subsequent debates in Parliament, following the recommendations of the committee, rarely entail a change of position. The number of ministries varies from one government to the next, but is as a rule about 20. In order to protect the interests of the ordinary citizen there is the om- budsman, an officer elected by Parliament. The office of the ombudsman is vested with considerable prestige. Any citizen can complain to him about the services given by public administration at local or central level. 1 Director, Hospi tal Division, Health Services of Norway, Royal Norwegian Ministry of Social A ff airs, Oslo. 2 Hea lth Planning and Evaluation Officer, WHO Regional Office for Europe, Copen- hagen, Denmark. 203 Local functions are carried out by 2 autonomous levels of local government, the counties (Amtskommune) and the municipalities (Kommune). A major revision of local administration boundaries was undertaken in 1970 ; the number of counties was reduced from 25 to 14 and the number of municipalities from 1300 to 277. This reorganization was followed by a number of new laws and regulations in the different administration sectors, in many instances transferring administrative responsibility from State to local government. Thus relieved of the major part of its operational administrative duties , the State administration devotes more of its time and resources to its principal task - evaluating the aims and practice of public service, proposing reforms , and fomrnlating the necessary legislation and re gulations. Denmark ranks among the top countries of the world in terms of both living standards and equality of wealth distribution, and since 1973 it has been a member of the European Community . The Danes enjoy a relatively high level of health . The average life ex pect- ancy ranks among the highest in the world - 76 years for women and 71 years for men . The infant mortality rate is steadily decreasing, now being around 13 per I 000 live births. The major health problems of Denmark are characteristic of the industri- alized societies. Chronic diseases top the list , with heart diseases responsible for a third of all deaths and cancer for another fifth. NATIONAL ECONOMIC AND LAND-USE PLANNING The overall responsibility for national economic planning falls on the Ministry of Finance. Recent economic developments have given the Danish people cause for concern as the worldwide economic recession has hit Denmark . While the unemployment rate in 1973 was only 2%, in th e 2 following years it reached nearly 12% before starting to fall towards the present (1976) figure o f 8%. I nllation was reduced from 13% in 1975 to about 9½% in 1976. The State budget for the financial year 1976-77 will nevertheless show a deficit of about 14%. The State budget is decided annually by Parliament , on the basis of the budget proposals by the Government. Additionally, the Govemmen t presents annually a budgetary review of proposed expenditure for the following 3 years, which gives Parliament the opportunity to discuss economic development over a 4-year period. Economic policy for the financial year 1976- 77 concentrated on com- bating the serious unemployment and related economic and social problems. The increase in State expenditure for the following year was limited to 6%, in spite of the expected increase of 7% in prices and salaries. The operating cost of the public services by the State , counties, and muni- cipalities reached Dkr 110 000 miJ)jon for 1976-77, financed (net of loans) mainly by taxation of income (54%) and value-added taxation ( I 6%). 204 As regards land-use planning, a law of 1973 introduced control mechan- isms for land use in order to promote a land development based on the pro- tection of natural resources and the separation of residential and industrial areas. Furthermore it laid the foundation for coordination of this development within the general framework of economic development, both on a local and on a national scale. An area development land-use plan must be made for each county, speci- fying the location of city development and of service units (including health institutions, communications, etc.). One major concern in this respect is the tripling of the urban area , especially within the 3 largest cities, during the last 25 years. The urban area now represents 4% of the total area of the country and another 1% has been earmarked for similar development. An important feature in regional planning is the emphasis on the develop- ment of a network of local centres large enough to ensure a minimum amount of employment and basic public services within a reasonable radius (I 5-20 km). As part of his responsibility, the Minister of the Environment must report to Parliament every alternate year on the progress of regional planning. In dis- cussion of the first report of this type, it was stressed that planning should be the vehicle for integrating sectoral plans (the health services in this respect be- ing a sector) and physical planning. County plans are currently being worked out. It can be assumed that final decisions on the plans will be forthcoming around 1980. The plans will contain fairly detailed provisions for development until 1985-90 and more general out- lines for the period up to the year 2000. Long-term forecasts for the financial and manpower needs of the health services were published by the Ministry of Finance in 1969, concentrating on the number of beds in health institutions and the subsequent need for re- sources. Similar long-term economic forecasts reviewing future development in all major public sectors (industry, agriculture, labour market, etc.) were pub- lished in l 971 and in 1973. These reports, covering the period 1972-87, also contained a chapter on the health services. DECENTRALIZATION OF HEALTH AND SOCIAL SERVICE ADMINISTRATION Recent legislation has accelerated the trend towards decentralization to- wards counties and municipalities. Railway services, police, postal services, and the customs remain under State administration, but in principle the municipal- ities have the administrative responsibility for most public services. The county administration is in charge of those services which cannot be provided for by each municipality in an efficient manner (for instance hospital services). The counties also have certain supervisory and coordinating functions with regard to the municipalities - notably in matters of planning. The State retains only those public services which are in less frequent demand and therefore not required in every county (as, for instance, certain 205 specialized nursing homes), and it also retains important supervisory, coordina- ting, and advisory functions in relation to both levels of local government. From the health service aspect, five ministries are of particular interest (Fig. 1 ). Under the Ministry of the Interior comes administration of the hos- pital sector, with two exceptions, namely the University Hospital, Copenhagen, which is the responsibility of the Ministry of Education, and the orthopaedic hospitals, which until 1 January 1978 were the responsibility of the Ministry of Social Affairs and thereafter that of the county councils. Primary care and social services are the responsibility of the Ministry of Social Affairs, while the Ministry of the Interior is responsible for the various preventive programmes such as public health nursery , district nursery, health examinations of preg- nant women and children of preschool age, contraception instruction, vaccina- tion and immunization programmes , and other preventive programmes. Finally, occupational health comes under the Ministry of Labour. The Ministry of the Environment is invested with the responsibility for important coordinating functions regarding planning matters , since regional planning, environmental protection, and (partly) food control come under this Ministry . Both the development of health services and their administration, planning, etc., have progressed gradually on the basis of modifications to old legislation and the introduction of new laws covering one particular type of service or one sector of service. For example, the Hospital Act of 1969 requires each county to establish and operate a sufficient number of hospitals , maternity clinics, and convalescent homes to cover the needs of the county population. In so doing the county is to cooperate with other counties and the State , and it may make special agreements with private institutions for the provision of some of these services. It is the duty of each county to provide inpatient treat- ment and ambulance transport to the population free of charge. In 1974 a new act on social assistance was passed that came into operation in I 976. It established the distribution of responsibility between the muni- cipalities, the counties, and the State for social services and some primary care within the health services. The purpose of the public service is to provide aid to those citizens who need counselling, economic aid, help to develop or retain the ability to work, nursing treatment, or educational support. The Minister of Social Affairs has the ultimate responsibility for the provisions of the act. At present (I 976) the responsibilities are distributed as follows between the State, the counties, and the municipalities. Psychiatric and somatic hospi- tals are the responsibility of the county except for the University Hospital, Copenhagen. The municipalities are responsible for general nursing homes, the county for psychiatric nursing homes, and the State for certain specialized nursing homes for young people. The State still has responsibility for the majority of institutions for the mentally handicapped, but the plan is to hand them over to the counties in 1979. However , the municipalities have respon- sibility for day-care centres for the mentally handicapped. The State operates certain rehabilitation institutions such as those for speech defects , for the deaf, and for the blind. The counties run the majority of the general rehabilitation clinics, including convalescent homes , while the municipalities are responsible for day institutions. The counties also have responsibility for inpatient institutions for alcohol and drug addicts, the 206 N 0 --..J Fig. 1. The organization of health services at national level Ministry of Labour Occupational health Ministry of Education University Hospital, Copenhagen GOVERNMENT Ministry of the Interior Hospital Council National Health Service Hospital Research Institute 14 counties (plus 2 municipalities) (somatic and psychiatric hospital services, general practitioner/special services, certain social services) County Council Association Ministry of Socia l Affairs National Board of Social Insurance National Board of Social Welfare ---- - Welfare Council rvIces tor mentally retarded, etc. 277 municipalities Institute of Social Research (social services, primary care other than general practitioner/special services) Municipal Council Association municipalities for the day institutions covering this service. To some extent the counties are responsible for the health services of general practitioners , medical specialists , dentists, and physiotherapists . Midwifery is the responsibility of the counties, while the municipalities take care of school health , child dental care, home nursing , and maternal and child health (public health nurses) .0 F INAN CING OF HEAL T H AND SOCIAL SERVICES The health budgets o f the counties and other local communes are financed from local income taxes and State subsidies . They meet the cost of all hospital and virtually all primary care, which covers medical care by a general medical practitioner and a private specialist upon referral, a portion of the cost for drugs, physiotherapy , spectacles for children under 16 years of age , dental treatment, medical transportation , etc. With rega rd to care by general practitioners, since 1961 Denmark has had a dual system. Under one system consumers receive medical care free of charge, with a free choice of practitioner once a year only, while under the second they are entitled to a free choice of practitioner - general or specialist - at any time , but in return they pay part of the expenses of care (averaging 50% or more of the total expenses for a consultation). From April I 976 each person was able to choose whichever scheme he preferred . About half of those pre- viously under the second system chose to switch to the first ; by Septem- ber 1976 , 93% of the population were under the first system. PubJjc funds pay 75% and 50% respectively of the cost of drugs appearing in 2 lists issued by the Ministry of Social Affairs. The patient is personally liable for the cost o f other drugs. Dental examinations and treatment are partly covered by public funds. Physiotherapy is free of charge when carried a Doctors arc trained in State universities for 6- 7 years, and some further training in hospit a ls and in ge nera l practice is required . For genera l practitioners this period is 3 yea rs, including a theoreti cal course in ge neral practi ce and social medicine ; for hospital doctors the spec ialist training is in appropriate hospital departments . A specia l commit tee under the Ministry of the Interio r regula tes and supervises the training of nurses. prac tica l nurses, labora tory assistants , physiotherapists, etc. The com- mittee consists of represe nta tives fro m several ministries, the Na tio nal Health Service, and the County Co uncil Association. Nurses receive a to tal of 3½ years of theoreti ca l and pra cti cal training in nursing schools attached to large r hospitals. There have rece ntly been discussio ns on whether the changing role of the nurse should lead to a reorganization of her training, with more impo rtan ce given to her role as a nursing coordin ato r and super- visor. For sen ior posts in the nu rsing profession, such as that of matron , I yea r of tra ining a t an adva nced schoo l of nursing education (provided at o ne o f the universities) is no r- mally considered a require me nt. 208 out on the recommendation of a doctor by a qualified therapist. In practice, trea tment by a chi ropractor is covered partly, even when the patient is not referred by a physician . Public health funds pay part of the cost of spectacles for children under 16 years of age and all medical atten tio n in connex ion with childbirth; they also pay death grants. Transport to and from a hospi tal is covered, as is trans- port to a doctor for emergency treatment. Practical ly all general practitioners have a contract with the county in which they work . The central negotiating committee of the public health funds represents the Cou!lty Coun cil Association, the Copenhagen and F rederiksberg municipalities , and the Muncipal Council Association. The Dan- ish Medical Association negotiates on behalf of private ge neral practitioners. It has been agreed that the annual income of a general practitioner wi ll corres- pond to the salary of a doctor in charge of a hospital depar tment (approxi- mately Dkr 250 000) plus an amount for office expenses, transport, etc. (about Dkr I 00 000) , i.e., a tota l of about Dkr 350 000 per year. Of this income ap- proximately 50% is paid on average as basic pay, the remainder being paid as fees for individual services according to an agreed schedu le. At present the standard contract for a ge neral practitioner is based on a practice of 1340 persons (excluding children under 15 years of age) and a 5-day (40-hour) working week . The cost of establishing and equipping a private physician office is always met en ti rely by the physician himself. Priva te specia lists outside Copenhagen have no basic pay, but they have a more independen t status than ge neral practitioners. However, they are obliged to adhere to official fee-for-serv ice charges. Hospital doctors engaging in private specialist practice must limit it to 3 hours daily after 3 p.m. Their re- muneration is the same as for private specia lists outside the hospital . As mentioned, the counties have taken over responsibility from the State for the runnin g expenses of hospitals , including mental hospitals , sec- ondary schools, and health insurance. Th e municipalities also took over from the State as from April 1976 important functions such as rehabilitation and maternal care. The financing of both deve lopment (investment) and operation (running) cos ts of inpatient institutions is the complete re sponsibility of each county council. The State pays all expenses fo r certain hospital services such as neuro- surgery and radiotherapy, which canno t be economically provided for an area as small as a county. If for some reason treatment of a patient has to be under- taken in another coun ty , reimburse ment is made by the home county . The municipality pays al l expenses regarding counse lling in accordance with the act on social assistance. The normal running costs of the o ther social and health services are partly refunded (50%) by the Sta te (the Ministry of Social Affairs and the Ministry of the Interio r). If the municipality runs a more expensive service than that which the State considers "normal", the deficit must be borne by the municipality. As a rule , the municipalities have a fair idea of what the State con tribution fo r the nex t budget yea r will be, so that they can prepare their budge t in advance with a reaso nable de gree of accuracy. Block grants to local governments are no t linked to specific services pro- vided but can be used at the discretion of the local government. About 10% of 209 the total block grant is given to reduce the gap between the more and the less wealthy local governments. The remainder of the grants comprise a general contribution to the local budgets on the basis of population, area, and road length (Table 1 ). Table 1. Block grants from the State to local governments: weighting factors Weighting factor Population Population by specific age groups Road length and area Total Weight in% Counties Municipalities 31 41 65 50 4 9 100 100 Block grants are increased each year in line with national and economic development and the general policy of decentralized decision making. They now amount to about 30% of total State contributions to local governments and to about 15% of net State expenditure. They correspond to more than one-third of the tax income of local governments. NATIONAL RESOURCES FOR HEALTH AND SOCIAL SERVICE PLANNING The principal national agencies engaged in health planning are the Ministry of the Interior, the Ministry of Socia] Affairs, the Ministry of Labour, and the Ministry of Education. There is a health division with some 30 professional staff in the Ministry of the Interior , which deals with the hospital sector, the primary care and national health service budget, drugs, the training of health personnel, and planning. These various tasks were earlier dealt with by 4 dif- ferent sections. Furthermore, a special section was established to serve as a secretariat for a commission on priorities within the health services set up by the Government in 1974 under the chairmanship of the chief administrator in the Ministry of the Interior. The commission was asked to procure the neces- sary background information and knowledge to change priorities in the health services and in disease prevention so as to utilize the limited resources in the most efficient way. The commission's work resulted in a report to the Govern- ment in February 1977. The special section has since then been engaged in follow-up activities in relation to the work of the commission. The Ministry of Social Affairs has a planning office with five professional staff, as well as an office for health insurance. 2 10 A special coordinating group between the chief administrators of the Min- istry of the Interior and the Ministry of Social Affairs has been set up . Special boards assist both Ministries in carrying out administrative functions, advise the Ministries , and supervise the counties and municipalities. Of the other ministries concerned, the Ministry of Education is responsible for the administration of the University Hospital, Copenhagen, while the Min- istry of Labour is responsible for occupational health services. The all-embracing role of health , the complexity of the health services , the need for an independent opinion, and the demand for guidance from local gov- ernment have made it necessary to create a special organization to provide technical and medical guidance on health matters. This guidance is provided by the Danish National Health Service, which is responsible for advising all na- tional and local public and private institutions. It has a medical director and is staffed with medical and other personnel. Although the National Health Ser- vice has few executive functions, the government bodies - both at ministerial and at local level - must consult it on all matters requiring medical or pharma- ceutical expertise; it thus has considerable influence on the development of national health services, policy and management. It helps the Ministry of the Interior directly in evaluating the hospital plans and projects of the counties and gives the Ministry its views on such plans and projects. With the changing distribution of responsibility fo r health services, the role of the National Heal th Service has also changed; it has gradually become more and more concerned with future development policy. Thus it has set up special working groups fo r the identification and study of new solutions to hos- pital and health problems. It also provides a medical report each year on the state of health and the health resources in Denmark. The National Health Service of Denmark comprises I staff unit for legal and administrative matters and 8 technical divisions (Fig. 2). Psychiatry is not established as a separate unit since psychiatric services are taken care of by the different divisions dealing with the particular question under study. There is no special planning unit. The planning aspects of the work are taken care of by the various divisions, in particular the hospital division . Special mention should be made of the public health officers. According to a special law enacted in 1973, each county constitutes an administrative area for the public health officer cadre. The number of public health officers varies with the size of the county. In principle they are all equal, electing among themselves one principal administrator and distributing their different tasks among themselves as they see fit. Employed by the Ministry of the Interior and professionally responsible to the National Health Service,a the public health officers advise public auth- orities at State , county, and municipal level on the planning and project im- plementation of medical, hygiene, environmental, and social matters. They also a The public health o fficers are , however , when they feel it desirable, free to consult the Ministry of the Environment , the Ministry of Social Affairs, the Nat ional Board of Social Welfare, and the Nat ional Board of Social Insurance. 211 IV IV Fig. 2 . Organizational structure of the National Health Service of Denmark I Medical Director I ~ Legal and administrative matters I I I I I I I I !General practi - International Materna I and tioner services health, child health, Drugs, Health Environ - epidemiologi - Faroe Islands, school health , radiation, statistics mental cal diseases, Greenland, chronic Nursing hygiene med icine surveillance, medical diseases, forensic licences care of the medicine elder Iv I Hospitals supervise the work of pharmacists, physicians, dentists, midwives, public health nurses , etc., in the county, undertake certain medico-legal functions, report on notifiable epidemic diseases , promote cooperation between different categories of health personnel, and so on. Another important agency is the National Board of Social Welfare, directly responsible to the Ministry of Social Affairs. It carries out a large part of State administration in the social sector and certain parts of the primary care sector, including services for children, rehabilitation services, and services for the men- tally retarded. The director of the Board is assisted in this by a social council appointed by the Minister of Social Affairs. The county councils, municipal councils, various ministries, the Danish Labour Association, and the Danish Employers Association are represented on this council. The Board supervises the operation of 11 regional centres for the care of the mentally retarded. These centres include a central institute for severe cases (250-1 JOO beds) , day-care centres , hostels, kindergartens, different schools, and a transport service. The Board is also responsible for supervising national institutes for the blind , the deaf, the crippled, and the epileptic. General rehab- ilitation services were transferred from the National Board of Social Welfare to the counties in 1976. Because of these and other changes in responsibility , the staff of the Board was reduced from 700 a few years ago to about 400. Further reductions can be expected when, in 1979, the counties assume responsibility for the care of the mentally handicapped , the deaf, the blind, etc. The National Board of Social Welfare has a planning unit with a staff of ap- proximately 30 persons. This is divided in to two sections, one for general policy development and one for the elaboration of plans for the State-run institutions, such as services for the mentally and physically handicapped. Both sections co llaborate in reviewing local plans on social services and primary care. The Minister of Social Affairs has the overall responsibility for health insurance matters. He is assisted in this by the National Board of Social In- surance, which issues regulations after due consultation with the National Health Service. In order to facilitate cooperation between the national organizations most involved in health services planning and operation, a special coordinating com- mittee (the "K-group") has been created, with members from the Ministry of the Interior, the Ministry of Social Affairs, the National Health Service, the National Board of Social Welfare , and the National Boa rd of Social Insurance. Special councils have also been established in such areas to provide the minis- tries and the boards with advice on policy. Thus , under the Hospital Act , a Hospital Council was set up by the Ministry of the Interior to assist the Na- tional Health Service in developing a hospital policy aiming at a high quality of inpatient care and efficient administration. This Council promotes coopera- tion between State, county, and private hospitals, and seeks to remove the barriers to efficient hospital use constituted by the county borders. The Hospital Council also gives advice to the Ministry of the Interior re- ga rding administration of the hospital sector. Its 11 members represent the Ministry of the Interior , the Ministry of Education, the Ministry of Finance, the County Council Association, and the municipalities of Copenhagen and F rederiksberg. 2 13 An analogous function in primary health and social services is fulfilled by the State Welfare Council, which has a similar structure and responsibility. The ministries, boards, and councils also draw upon the work of several re- search institutes to help them clarify various technical issues. Critical evalua- tion of medical performance and basic research to develop tools for the diag- nosis and treatment of patients go on in various medical institutes and in many hospital departments around the country, in particular the university hospitals. Traditionally , research in these institutes has centred more on the purely medi- cal aspects, but two of the universities have now established institutes for general practice. The State Council for Medical Research also undertakes studies that have a bearing on health service policy problems. A Hospital Research Institute was founded in 197 5 with the purpose of collecting, analysing, and disseminating pertinent information and of carrying out research on the planning, rationalization, and operation of the hospital and health services , with a view to facilitating the task of the planning and governing authorities within the health services. Of the lnstitute's finances 50% is covered by the budget of the Ministry of the Interior , the remaining 50% by the 14 coun- ties and the 2 municipalities of Copenhagen and Frederiksberg. The counties pay their contribution as a block allotment from a special fund which is at the counties' disposal from the value-added tax. These contributions give the Institute considerable freedom to formulate its own research policy. The bud- get for 1976 was Dkr8 million, of which Dkr2 million went to contracts with universities, consultants, etc. The director of the Institute is responsible to an I I -man board appointed by the Ministry of the Interior, the County Council Association, and the muni- cipalities of Copenhagen and Frederiksberg. A council of experts acts as an advisory body to the board and to the director. This scientific council has at the moment 11 members comprising doctors, economists, architects, nurses, and engineers. The scientific council members are appointed on their personal merit by the Board of Governors. The Institute had in 1976 about 20 staff, comprising doctors, engineers, economists, nurses, political scientists , etc. The tasks of the Institute are not restricted to hospital services but include other parts of the health services as well. One of its first priorities has been the establishment of a data bank relevant to hospital and health services planning, and it has established collaboration with similar institutes in the Federal Re- public of Germany, Norway, Sweden, Switzerland, and the United Kingdom. The data bank will be automated and be available to users at both the local and the national level. The Institute is involved in 19 projects in 5 different fields. These cover a wide range of subjects, including medical care in hospitals, primary care, or- ganization of hospital departments, maintenance, safety, functioning of medi- cal instruments, planning of hospital services in a county, hospital design, and the use of computers . The research policy of the Institute includes the creation of project groups composed of personnel from the Institute itself, from the health services, from the universities, from the Medical Association, etc.; thus a large number of people are directly involved in research and development, amounting already to several hundred. 214 On a parallel with the Hospital Research Institute is the Institute of Social Research, whlch is, however, of much longer standing. Like the Hos- pital Research Institute , it is not connected directly with the National Board of Social Welfare but has a somewhat independent position under the Min- istry of Social Affairs. The National Board of Social Welfare is represented on the Board of Directors of the Institute, as are several ministries. This In- stitute has produced many interesting research reports, such as on the ef- fect of disease and disease intervention on the patient's family life , work , and other social factors. The National Board of Social Welfare utilizes some of the results produced by this research in formulating policy. Finally, the counties have created a national agency for collaboration - the County Council Association - in order to assist them in the development of a common policy and to provide assistance in their administrative duties. The County Council Association has a staff of about 80 persons, organized in 8 dif- ferent units. Three of these units deal with health-related problems (hospitals , social affairs and primary care, and the training of health personnel , res- pectively). While the Association does not give direct assistance to the individual counties in hospital planning, it organizes planning conferences for discussion of hospital and general health policy development. In addition, it participates in a number of working groups, studying different problems regarding hospital and health care development. In such instances the Association does not have any power to enforce decisions on the counties. However, it negotiates general practitioners' and other similar contracts, and in these matters its signature is binding on the counties. The municipalities have a similar association - the Municipal Council Association. Thls gives guidance to the municipalities in all areas of their ad- ministrative duties, including social services and ce rtain parts of the primary care services. Informal planning resources are also important. Ideas for health service development come from many sources ; scientists , health personnel and their associations , health administrators, politicians , and individuals all contribute to new trunking in health as in other fields. While plans made by municipalities and counties are submitted to the Government, the latter gives little information to the local authorities with regard to those health services whlch are at present operated by it, such as the mental health services and parts of the care for the physically disabled . NATIONAL PLANNINNG OF THE HOSPITAL SECTOR Although considerable reforms have been carried out in recent years, the present situation is characterized by a number of different planning 215 systems. Two major systems exist, one for hospital planning and another for social services and primary care planning.0 The Hospital Act requires each county council to prepare a plan for its hospital services, covering the administration and use of hospitals and ma- ternity and convalescent homes. Each plan and any subsequent changes must be submitted for official approval to the Ministry of the Interior after being evaluated by the Hospital Council. The area of dense population in and around Copenhagen was merged into I planning unit for hospital services, comprising so me 2 000 000 people in 3 counties and 2 municipalities. The plans made by these 5 local govern- ments are coordinated with State plans for the expansion of the State hos- pitals in the area . Draft plans pass through a metropolitan council for coordina- tion and adjustment, before the plan for the whole area is finally submitted to the Ministry of the Interior. The hospital plan contains a description of the present structure of hos- pitals and similar county institutions and evaluates it in relation to health services policy and county development. On this basis a plan is made for the services to be provided, the service units to be established, and the future need for staff, capital investment, and operating expenses. In I 97 I the Ministry of the Interior sent guidelines to the counties re- garding the planning of future hospital development. Among these were pro- posals that the more specialized hospital services should be concentrated in one hospital in each county so that future specialization could take place there, and that certain regional hospitals should provide the most specialized hospital care for several counties combined. The other hospitals in the county should continue to provide more general hospital services. The necessity of promoting functional coordination between the hospitals was therefore stressed. The guidelines further stated that plans should cover a 15-year period, but for the time being the trend is to concentrate on a period of 5 years. Neither the law nor the guidelines specify when the first round of planning should be completed in the counties, nor at what intervals the plans should be renewed. By September 1976 - 7 years after the law was adopted - 4 of the 0 The country has a total of 140 hospitals with some 43 000 beds, IO 650 of which are in 70 mental hospitals. Of 123 hospitals 34 are specia lized (3000 beds), while the re- maining 99 are general, including 9 large ( IO 800 beds), 33 medium-sized , and 57 smaller. On average there are about 6 genera l hospital beds per I 000 population . In the I 960s and the early 1970s an extensive building programme for hospitals was carried out , cu l- minating in 1975-76 with the opening of 2 large hospitals in the Copenhagen area. There arc no cottage hospitals in Denmark. On the other hand, nursing homes rep- resent a very important feature in Danish health services, providing both inpatient and outpatient care (day care). In 1975 a total of 81 000 persons worked in the Danish hospitals. Approximately 56 000 of these were health personnel , of whom 5500 were doctors ( 1600 consultants and 3900 junior doctors) and 36 000 nursing personnel (qualified and student nurses) including about 17 000 registered nurses on a full-t ime equivalen t basis. About 2900 were administrative staff. 2 16 14 counties had still not completed plans. The plans submitted to the Min- istry of the Interior concentrated mainly on the building and financing of new hospital and related facilities rather than on the service content of hospitals and their linkage with other parts of the health service. Before the plan goes to the Ministry of the Interior it is reviewed by the National Health Service with special regard to the completeness and appropri- ateness of the hospital services to be rendered, the effectiveness of the hospital infrastructure, and the efficiency of resource use. The Hospital Council provides a second opinion before the Ministry arrives at its own final decision. It is not quite clear at present to what extent the Ministry has the power to change the plan and how binding its decisions will be with regard to sub- sequent development. So far only six hospital plans have been finalized in the Ministry of the Interior. The policy of the Ministry seems to be a step- by-step acceptance of the plan . The Ministry accepts only those parts of the plan with which it agrees; when it does not agree on some point it returns this part of the plan to the county council for further consideration and a new evaluation takes place when the county resubmits the plan. It thus appears that the Ministry of the Interior does not make explicit changes itself. It should be noted that the Ministry does not have a veto over capital investment, hos- pital budgets , or hospital manpower. The decision by the Ministry is only binding with regard to the service content of the plan and only indirectly with regard to the use of resources, since there is as yet no mechanism for up- dating plans at yearly intervals. Project plans for hospital construction must be submitted by the counties (or private hospital owners) to the Ministry of the Interior for technical ap- proval before construction can be started. The Ministry sends the plan to the National Health Service, which reviews it, concentrating on the more general functional aspects rather than on the details (as it did some years ago), to see whether the various hospital departments are well placed in rela- tion to one another from the point of view of communication, etc . On the basis of this review, the Ministry of the Interior gives its approval or com- ments on the plan. While the Ministry is vested with the legal power to reject the plan , in reality it does not have effective means at its disposal to enforce its views, since there are no longer investment ceilings or buildin g quotas for the counties (although there is State control over how much foreign loan a county can take up) . The guidelines of 1971 issued by the Ministry of the Interior have already been mentioned. Although no major policy document has been produced since then, the Ministry has let it be known that the counties ought to concentrate less on increasing the number of hospital beds (in an effort to keep the present bed: population ratio) and more on outpatient services and on functional coordination among hospitals and between the hospitals and the primary care sector. As a step towards setting priorities more clearly among different health services, a commission was, as mentioned earlier, set up in 1974 comprising representatives from the various ministries and boards, Parliament, the local authorities, and the Danish Medical and Nursing Associations. The work of the committee concentrated on the structure, methods, and information 2 17 system needed for the coordinated planning of health services. The committee also investigated the present problem of fragmented responsibility for health services administration and planning. The Ministry of the Interior reviewed its recommendations in 1977 . As a result of the recommendations it has already been decided to change the present rules for hospital planning in order to coordinate the procedure and timing of hospital planning with the planning in other public service sectors such as education and the social services, where the plans are revised every fourth year. The revision of the planning rules will take into account the ex- perience of the first hospital planning period. A new 4-year planning period started in 1979. NATIONAL PLANNING OF THE PRIMARY CARE AND SOCIAL SERVICE AND OTHER HEALTH SECTORS0 The law on the development of social services requires each county to make a plan for the development of social and health services other than those mentioned in other laws ( especially those on hospital and medical services). The planning process starts with each municipality of the county making a pro- posal for such services within the municipality. The draft plans are then coor- dinated with other health and social services. In 1974 the Ministry of Social Affairs sent guidelines on planning to the counties, specifying that the plan should contain the following information: a discussion of the objectives and targets for the different types of service in- cluded, a set of tables for standardized presentation of the quantitative aspects of the plan, and finally comments (tables and text) explaining the basic prin- ciples of the planning, the content, and the important factors influencing the proposals presented in the plan. With regard to health services, the plan should contain information on home nursing, preventive child health care (preschool and school), preventive child dental care, and contraceptive education. The first round of social service and primary care planning took place in 1975. The deadline for the presentation of the first county plans to the Min- istry of Social Affairs was I April 197 5 - a deadline that was, on the whole, observed. At central level the plans were first reviewed by the National Board of Social Welfare. Comments were then sent from the Board to the Ministry of Social Af- fairs, with copies for information to the counties and municipalities. The Ministry then asked the opinion of the Ministry of the Interior about the plans in order to ensure coordination at central level with hospital planning. a Less than half of the 2300 general practitioners working in 1975 were in single practice, the remainder being in some kind of group practice. Of 26 000 nurses working in Denmark in 1975 , 17 000 (calculated on a full-time basis) worked in the hospital sector and about 6000 in social welfare and primary care . 218 In September 1976 the central authorities were in the midst of a second round of plan evaluation. Substantial differences in quality in the planning of the different municipalities and counties were apparent. The National Board of Social Welfare publicly criticized 11 municipalities since many of the county plans overemphasized inpatient services in nursing homes at the expense of out- patient services in institutions for children and the young. It was expected that the Minister of Social Affairs would call upon at least IO counties for further consultations and amendments. As regards the Mjnistry 's legal right to approve the plans formally, the guidelines of 1974 stressed that the Ministry would not, in giving its approval , judge whether the various goals and objectives of the plans were considered appropriate by the central authorities. The plans at present aim primarily at giving the central authorities a general overall view of the ideas of the counties with regard to future development, resource use , and the need for coorilina- tion with other types of planning. It is uncertain what powers the Ministry has to enforce decisions, since it controls neither the funds needed for investment for the services contained in the plan nor the number of personnel hired by the counties and municipalities to fulfil it. It does, however, control the levels of reimbursement it will make for the different types of service given (nursing home care , etc.), but such levels of reimbursement cannot be changed from one county to the next. At present the counties make only 1 plan and there have been discussions as to whether they should not present several alternatives. With regard to the time span for planning - at present 5 years - the Ministry of Social Affairs is about to embark on 15-year planning, which will contain several alternative suggestions for future social and health policy. This 15-year plan will also contain rough estimates of the future need for resources and the possible consequences of social and health plans for other sectors of society. The 15-year plan will be reviewed at regular intervals ; how frequently has not yet been decided. The counties and murucipalities will dovetail plans on the local level into the national plan. Plans for the building of health institutions other than hospitals (such as nursing homes and other institutions run by the municipality) are not submitted to the Ministry for approval, but the county is responsible for seeing that the plans made by the municipalities are accordjng to the rules and regulations laid down by the State. In 1973 the Murucipal Council Association published its views on current problems, new laws, and future policy with regard to the municipal administra- tion of social and primary care services. This publication states the duties of the municipalities and their councils in relation to the new laws, presents models for local government organization in this field , and emphasizes the need for co- opera lion between the various service units and adrrunistrative levels . Hospital sector planning and the planning of social services and certain pri- mary care services are fonnal health planning systems, as they are based on speci- fic laws and represent large planning exercises involving all levels of public administration. There are, however, a number of other health services not included in these formal planning systems for which there exist, or are fore- seen, planning exercises of varying scope and complexity. The more important 219 of these concern planning for general practitioner and private specialist services, the physically handicapped, the mentally handicapped, occupational health , psychiatric services, institutions for alcoholics, and medical transportation. As regards planning for general practitioner services, each county council has accepted the plan dividing the county into a certain number of general practitioner districts. In each district the council decides the number of posts for general practitioners. Several study groups have recommended nationwide planning for general practitioner services. In 1976 the Medical Association (through its subgroup for general practitioners) and the central negotiating council of the public health funds agreed to start such planning on a county basis. The aim of each plan should be to achieve reasonable coverage and quality of general practitioner services, taking into consideration their relationship to other social and health services and offering the population a reasonable choice of doctors. As a general norm it has been recommended that the plan should aim at I general practitioner for each 2000 inhabitants. However, special conditions (such as the age distribution of the population) should be taken into consideration throughout the planning stages. The plan will cover a certain time period - 5 or IO years - but no definite decision has yet been made as regards the period. The plans are to be subject first to county approval, as for any other county plan. Final approval will be given by a 6-member national collaboration council for general practitioner services, half of whose members represent the general practitioners' association and the other half the central negotiating committee of the public health funds . The Health Security Act was changed in 1977, so that the Ministries of Finance, the Interior , and Social Affairs now have each a representative . It has also been proposed that planning should be started for private specialists and that medical assistance to the social and health services of the municipalities should be established through part-time consultation by pri- vate practitioners. There are no direct State regulations on the total number of personnel employed in the health services, nor are there any binding manpower ceilings for the counties. The State can influence the local authorities only indirectly by regulating the refunds given to them, since the State refund (e .g., to nursing homes) is based on a State norm for staffing ratios. The only area in which the State attempts regulation is with regard to the number of doctors. Whenever a county wants to establish a new consultant post in a hospital it must submit this proposal to a committee which has mem- bers from the National Health Service, the Ministries of Education and of the Interior, the Danish Medical Association, and the County Council Association. While the committee's decision is not binding on the county in question, there is a gentleman's agreement that the counties will abide by the decision and practice has shown that this is normally the case. In its decisions the committee tries to promote a more even distribution of physicians among the counties of Denmark. The decisions of this committee concern only the establishment of new posts. However, whenever a consultant post is about to be filled in a Danish hospi- tal , the National Health Service must give its views , based on a professional 220 judgement, on the relative standing of the candidates. The county is not , how- ever, bound to follow the priority list established by the National Health Ser- vice when making its final selection among the available candidates. Until recently there was only ad hoc planning of services for the physically handicapped . In 1977 a 5-year planning effort was started by the National Board of Social Welfare. The National Board of Social Welfare in 1975 produced policy guidelines for services for the mentally handicapped (more decentralized services, more community services for the mentally handicapped, etc.). Twelve State regional mental health centres produced plans for the year commencing in April 1977 and non-binding estimates for 1978-8 1. Planning for the physically handicapped - the deaf, the blind, etc. - is another field where the National Board of Social Welfare now in tends to start a regular activity, following the lines now used in planning of services for the mentally handicapped. As is the case with the latter , this new planning system will be entirely a State responsibility in the beginning but, when the services for the mentally and physically handicapped are transferred to the counties, the planning systems will have to be adapted accordingly. With regard to occupational health services, there are at present only some 70 industrial enterprises in Denmark that have some kind of medical occupa- tional health service, together with 18 establishments that employ nurses for the same task . In 1975 there were also about 135 physiotherapists and 110 work therapists employed in Danish industry. The occupational health service is mostly concerned with screening examinations, while preventive aspects - main- ly accident prevention - have mostly been dealt with by regional inspectorates under the Ministry of Labour. Following an ILO agreement, the Danish Labour Union, the Danish Em- ployers Association, and the Danish Medical Association formed a committee to study occupational health services in Denmark. This committee in 1975 presented several alternatives for the organization of occupational health ser- vices and pointed to the importance of coordination between occupational health services and primary care services. It also gave a rough estimate of the resources needed to develop the occupational health services along the lines proposed. A law of 1975 on the protection of the working environment authorized the Minister of Labour to plan for occupational health services. The Ministry has now to study the recommendations of the committee and propose the necessary rules and regulations, including planning directives. The field of psychiatric health services is another area under scrutiny at present. The current inclination is to avoid the big specialized mental hospital, and to integrate psychiatric hospital services more into the general hospitals. This will gradually lead to the establishment of a psychiatric department in the main hospital of each county and to close cooperation with primary care by the creation of multidisciplinary teams of doctors, nurses, and sociologists for a de- fined population area. A special study group appointed by the Ministry of the Interior has considered a planning system for this. The Ministry issued guidelines for the planning of psychiatric hospitals to the county councils in 1977. With regard to the transport of the ill or the injured , ambulance services are provided throughout the nation by a private company, while the Air Force 221 provides helicopters or aircraft when necessary . In 1974 the Ministry of the In- terior , after consultation with the National Health Service , appointed a 20-man committee to study the ambulance service. The committee included representa- tives of the various ministries and boards concerned with the health services , as well as representatives from the private ambulance service, the Danish Medical Association, the County Council Association, etc. It recommended that each county make a specific plan for transport that ensured effective coordination and communication between the ambulance services, the hospitals, and other health services (especially general practitioners) and a safe and appropriate means of transport for every patient.0 It is expected that the Ministry of the Interior will make rules and regula- tions based on the recommendations of the report, specifying also what kind of planning system should be adopted for this type of health service. INf-ORMATION SYSTEM f-OR NATIONAL HEALTH PLANNING In Denmark demographic information is provided by the Central Bureau of Statistics, both on a national and on a local scale . In addition, the county administrations often make their own population estimates. These invariably forecast a higher population than the Central Bureau does. The new system for national and regional planning will improve the availability of information on population distribution, manpower , local communications, etc ., at both local and national level. Ideally health planning should be based on the analysis of disease- and accident-producing factors in society. It is not possible to have complete and reliable infonnation on disease-creating factors, but at present such informa- tion is relevant and potentially available for certain fields. One factor is the non-immunity of the population or of population groups to infectious diseases, as measured by the immunization status of the population. At present there is no complete information available on the vaccination status of the Danish population, although public health officers can obtain such statistics from public health nurses and doctors in their area. However, with regard to tuber- culosis, an extensive registration of cases has been kept at the national level by the Danish Institute for Clinical Epidemiology and selective screening can be planned on this basis. Denmark has a special medical registration of births that covers all births in Denmark and contains details of complications in pregnancy and delivery of value in prognosticating development problems in the child. 0 It is of interes t to note that the committee did not reoommend specia l ambu lances for cardiac emergencies as a routine part of the ambulance service, although it advised that further practical experience should be obtained with this kind of service . 222 Regarding the incidence and prevalence of disease, the public health of- ficers forward reports on a number of infectious diseases to the National Health Service . A special reporting system - the "blue system" - reports the diagnosis of all patients admitted to Danish hospitals. This information is com- puterized and stored by the National Health Service. At present there exists no information regarding outpatient activities at hospitals or the activities of general practitioners and specialists (apart from the aforementioned information on infectious diseases). There is a special cancer registration system - operated by the Danish Cancer Registry - which gives complete information on the incidence and prevalence of can- cer in Denmark , and the Danish Council on Smoking collects information on the smoking habits of the population. For heart disease - the most promi- nent disease in Denmark - there exists at present no information on disease- producing factors that could effectively be used in designing a preventive health programme. Nor is there as yet an information system that system- atically collects data on factors producing accidents (whether at home, at work, or on the road) or on occupational diseases . In formation on disability in the population is potentially available since such information is given in sick- ness allowance requests to the health insurance fund. However, this infor- mation has not yet been systematically collected and analysed for health planning and evaluation purposes. With regard to health services utilization - the number of patients treated, of preventive measures undertaken, of diagnostic examinations performed, etc. - the present blue system gives information regarding the number of patients treated in hospitals, the number of operations performed, the diag- nosis, the age group of the patients, and so on. The social security system also has information on the number of patients seen by general practitioners and specialists and the number of different procedures carried out by these doctors according to the fee-for-service itemi zed list . So far there exists some - but not very extensive - information on treatment and diagnostic examina- tions in hospitals. Information on the workload of health personnel is available only on a very broad scale (such as the number of different categories of different health personnel as compared with the number of patients treated per hospital department) . The National Health Service keeps manpower statistics on the hospital secto r and the Central Bureau of Statistics has similar information on the social services and primary care services. Information on investments and operating costs is available at the central level through the annual plans for social services and part of the primary care services, the reports to the National Board of Social Insurance (on general practitioners and specialist services), and the annual reports to the National Health Service regarding the hospital sector. Information on deaths is readily ava ilable in the National Health Service and the Central Bureau of Statistics . At present two important developments are taking place that may sub- stantially improve the in formation available for health planning in Denmark in a few years' time . One is the new budgetary system at present being de- veloped, which will ultimately be a unified system for the economic and 223 manpower budgeting of municipalities, counties, and the State. This system will be quite detailed and will also identify small operational units, items of service, and types of expendi ture. The new system started in I 977 but will probably not be fully implemented at all 3 levels of public administration until the end of the I 970s. The period covered by the system will be 3-5 calendar years, with annual reviews. Each review will include all investment and operating costs deriving from the various local health services. The State will also adopt this new budgetary system, but at a somewhat later date. It may therefore be expected that, in the near future, municipal, county, and State budgets will be coordinated, reviewed every year, and extend over a 3-5 year period. The second important development is a new hospital information system being tested at present in some pilot areas. This system has been developed under the auspices of the County Data Organization (Kornrnunedata), which is a collaborative effort of the County Council and the Municipal Council Associ- ations, and it consists of a network of computing centres for the local authori- ties . The Organization has a special unit for health service computing, con- sisting of about 80 people working in 2 centres (one in Aarhus in Jutland, the other in Copenhagen). These centres develop health service data-processing programmes and provide on-line computing facilities for hosp itals wanting to buy such services. The information contained in this new "red" system comprises information on patient identification (name, address, personal identification number, etc.), diagnosis, o perations , complications of treatment, anaesthetics, results of pathological laboratory tests , etc. It can also give in- fom1ation on resource use (number of man-hours per operation, per category of personnel, etc.). The new system in this respect is built in modules , and it is up to each hospital to decide which modules it will utilize. The system is based on on-line contact between a computing centre (used for medical computing only and equipped with special safety systems) and in- dividual hospitals. In principle each hospital retains a complete power of deci- sion over its own information and th e computing cent re cannot supply any confidential information (tliis would have to be done by the hospital itself if necessary). At the moment 3 counties (with a total of 30 hospitals) have started using the system, and it is hoped that all the counties in Denmark will gradually be connected to it. For the moment the system only covers inpatient care, but in 2 or 3 years' time it will be expanded to include outpatient care. With regard to primary care activities, there is no plan to include these in the new infom1ation system for the time being. AAR HUS COUNTY: ADM INI STRATION AND HEALTH SERVICES Owing to the decentralization of power that has taken place in Denmark in the last decade , the counties have emerged as important administrative units with regard to health, education, roads, and other sectors. As a consequence, the administration at county level has been considerably strengthened. 224 The local government reform of 1970, which reduced the number of counties from 25 to 14 , created new counties with an average population of about 285 000 people . Except for the island county of Bomholm (popula- tion: 47000), these counties have a population range of from 170000 to 624 000 ( 1973 figures). To study the health services and health planning at county level the county of Aarhus on the peninsula of Jutland was selected. Aarhus County has a population of approximately 560000 people (1975 figures) and an area of approximately 4500 km 2 , approximately 11 % of the population and the area of the country. It contains 26 municipalities ranging in size from approximately 4500 to 232 000 people, the latter cor- responding to the municipality of Aarhus, the county seat. The population density in the county is quite high being 123 persons per km2 (I 17 per- sons per km 2 for Denmark as a whole). Of the population , 80% lives in ur- ban areas, corresponding to the national average . The ne t increase of pop- ulation in the county has declined from 1.8% in 1970 to 0.7% in 1974. The population aged 65 years and over corresponds to 12.4% of the total popula- tion (in 197 5) . From a geographical point of view the county consists of one mainland area and smaller islands. It has about 7000 km of good roads, railway con- nexions between the major population centres, and an airport. The county budget for the fiscal year 1975-76 (the Danish budgetary year runs from April to March) was Dkr 1226 million, and that for 1976- 77 was Dkr I 560 million, an increase of 27%. As shown in Fig. 3, the hos pi ta! sector alone is responsible for 59% of total expenditure, with other health and socia l services taking another 22%. The county gets its income mainly from direct taxation (Fig. 3). Of the income 48% comes from income tax, 11 % from property tax, 33% as block grants from the State, and 6% is re- funded from the State for specific services. The unemployment rate in the county in 1974 was 5.2% (corresponding to the national average), an increase of 2.1 % since 1973. The central organization of Aarhus County is a closely integrated system of political and administrative bodies. As shown in Fig. 4 , the County Council is the governing body of the county, consisting of 31 members representing 8 different parties (in 1976). The Chairman of the County Council - the County Mayor - has overall responsibility for the county . The County Council selects from among its members 5 standing council s or committees, each with 7 members. One of these - the Economic Counci l - deals with financing and overa ll planning for the county. This council therefore holds a key position and all budgets and plans from the other 4 standing councils must pass through it before they go to the Co unt y Council for decision. The Hospita l Council dea ls with hospital administration and development , wh ile the Social and Health Council deals with socia l services and primary health care. The Technical and Physical Council is responsible for land use , roads , water , and sim il ar topics. Education and other cultural matters are taken care of by the Cu ltural Council. 225 Fig. 3. Income and budget distribution, Aarhus County, 1976-77 226 Income tax 48% Social and health services 22% Interest 2% Hospitals 59% A. Income distribution Grants based on tax levels Block grants 33% Property tax B. Budget distribution Education and culture Repayments and investments Administration, 1 % Roads, water, and planning N N --..) Fig . 4. Political and administrative organization of Aarhus County l Hospital Council I I I I Hospital admini stration l I I Technical and Physical Council I I I I I Technical and physical ad ministration I COUNTY COUNCIL l I Economic Council 11 l Central administration I Cultural Council I I I I I Cultural administration I I Social and Health Council I I I I Social and health administration I t I This political organization represents the decision makers in the county , supervising the county services and county administration and approving county budgets and development plans. The politicians do not work full- time on these tasks. The central administration of the county, headed by the county director, is the executive body of the County Council and the Economic Council. Each of the other 4 standing councils has its own executive administration, headed by a director , who is the secretary of the Council. The County Council , its 5 standing councils, and their executive administrations thus constitute I organ- ization, with delegation of authority from the County Council to its 5 standing councils and further from the latter to the directors of the 5 executive admin- istrations and their staff. The most important of the 5 executive bodies is the central administra- tion, with its legal and economic sections. Its tasks include the preparation of the annual and the long-term budgets for the county (the latter comprises 3 additional years), and it is responsible for the coordination of the different sector plans into an overall infrastructure plan for the county. Plans produced by the other 4 administrative divisions must pass the central administration be- fore they can be submitted to the political superstructure in a final version. The divisions for hospital administration and for social and health services will be described in more detail in the following two sections. The division of technical and physical services contains three depart- ments - one for roads, one for pollution, waterways, and other environmental protection problems , and one for land-use planning. The latter is responsible for making the draft for the overall infrastructure plan, but it cooperates closely with the central administration in this respect. The cultural administration looks after secondary schools and other edu- cational matters. Cooperation between the administration and the political structure is close. The chairmen of the councils have permanent offices in the correspond- ing administrative divisions and work there almost daily . As a rule, councils meet every second week. The very frequent meetings of the councils and daily contact with the council chairmen have led to a situation where a large number of administrative decisions are taken by the councils. In principle, the admin- istration deals with all matters within the limits of the budget. As is evident from Fig. 4 , the organization of health services at county level is divided into two main areas - hospital administration on the one hand and the rest of the health services and the social services on the other. This division is evident both in the administrative and in the political organization of the county .0 0 It is of interest to note that the county health administration docs not at the moment have any physicians on its staff. l11e public health officers of the county are officials of the State, as local representatives of the National Health Service. Their areas of responsibility are not coterminous with hospital areas, general practitioner districts, or otJ1er health service areas. 228 A similar division between hospital and other health services was pre- viously also found in the Danish Medical Association . However, in 1971 the Association reorganized its structure, creating unified local branches by merging at county level the 3 former associations for general practitioners, consultants, and junior hospital doctors. The largest part of the county health services is the hospital sector. Aarhus County has a total of 15 hospitals ranging from very specialized highly differ- entiated ones (Aarhus Kommunehospital) to small undifferentiated local hospi- tals. There is I mental hospital of 700 beds (a State hospital until April 1976, with 3 psychiatric nursing homes attached); I large university hospital of a regional hospi tal type (Aarhus Kommunehospital, with about 1400beds);3 cen- tral hospita ls (well-differentiated hospitals with about 400 beds each); 3 smaller hospitals (some 150 beds each) with departments of general medicine, general surgery, anaesthetics, radiology, and pathology ; 3 mixed hospitals (30-80 beds); and 4 specialized hospitals (3 for aftercare and I for dermatology and sexually transmitted diseases - all small). In addition there is a mixed institution - part medical , part social - for the care and rehabilitation mainly of alcoholics and drug addicts under the social and health administration. In addition , the State had an orthopaedic hospital, with 125 beds, in the area, which was taken over by the county in J anuary 1978. The tota l number of somatic hospital beds in 1975 in the county was 3595 . However, the county has regional obligations to other counties within the fields of radiotherapy , neurosurgery, heart surgery, e tc ., and the above- mentioned figure cannot therefore be used as an index to hospital utilization by the population of the county. If only the number of beds occupied by the population of the county is considered - including also beds in hospitals in other counties - it corresponds to a figure of 5.7 beds per I 000 inhabitants, i.e. , close to the nationa l average. A to tal of 94168 patients were admitted in 1974-75 , corresponding to 16.8% of the population. These patients spent a total of 1 031 341 days in hos- pital, corresponding to approximately I I days per patient on average. The county employs some 9000 staff in its hospital sector, with an annual budget of some Dkr 887 million ( 1976- 77). This figure takes into account pay- ment by the State for part of neurosurgery and radiotherapy costs, and by other counties for their patients. This corresponds to approximately Dkr 1500 per inhabitant per year. The investment in hospital construction during 1976- 77 amounts to Dkr 50 million for Aarhus County. The total expenses of the hospital sector - including outpatient services - are paid by the county. Th e 7-member Hospital Council supervises the work of the county hospital administration, which again supervises the individual institutions under its jurisdiction . The county hospital director is chief of the county hospital ad ministra- tion, an administrative unit with responsibilities that include budget and finance, secretarial functions for the Hospital Council and electronic data- processing. The hospitals of the county do not have boards of their own. The hos- pital administrator (always nonmedical) is directly responsible to the county 229 hospital director for all aspects of administration except medical and nursing matters (which come under the medical department chiefs and the matron respectively).0 Each hospital is subdivided into several departments - the medical depart- ments (surgery, radiology, etc.), the nursing department, and administration. The medical organization of a hospital is hierarchically structured, each medical department chief having under him a number of assistant department chiefs and junior doctors. At each hospital there is a medical committee elected by the doctors themselves, which represents the interests of the medical staff in the administrative and political management of the hospital. The chairman of this committee often represents his colleagues in discussions related to management of the hospital. The committee has only advisory status, but it wields considerable influence in most hospitals. The nursing staff in the hospital also work within a hierarchical system ranging from the registered nurse, staff nurse, and head nurse up to the matron (chief nurse), who is head of all the nursing services in the hospital. These include a large number of so-called nurse assistants (practical nurses) who have taken over much of the basic nursing work in hospitals and other institutions. In addition to its involvement in the hospital sector, the county also has certain responsibilities for general practitioner and private specialist services as well as certain other health services. The 7-man Social and Health Council has the responsibility of supervising the social and health administration, which carries out the practical tasks, serves as a secretariat to the Council, and in turn supervises the work of the county health funds department, the county social centre, and the social institutions of the county. It also to some extent serves the social services of the municipalities in an advisory capacity. Services by independent general practitioners and private specialists are contracted out by the county health funds department. This depart- ment handles some 6 million bills from the health insurance every year, which totalled some Dkr 257 million for the financial year 1974- 75. Each doctor must contract with the county, which regulates certain conditions of his work, including the financial remuneration. The county health funds de- partment, subject to guidance by the Social and Health Council, is the ad- ministrative unit responsible for such contracts and for ensuring that doctors in the area fulnl the terms of the contract. The county is divided into 28 gen- era l practitioner districts , the 295 general practitioners in the county being allocated to these districts with a mininium of2 general practitioners in each. The latter requirement is intended to ensure that the population in each district has a choice of doctor. The general practitioner districts are not congruent with the 4 hospi tal areas. 0 The administratio n of the individual hospita l cannot hire additional personnel with- o ut the agreement of the County Council, nor can funds be switched among the budgetary items o r be transferred from one budgetary yea r to the next without the specific approval or the County Council. 230 During the fiscal year 1974-75 these 295 general practitioners served ap- proximately 4 70 000 persons under the first insurance scheme, making app roxi- mately 2 118 million contacts with them ; this makes an average of about 4.5 gen- era l practitioner contacts per person per year. Of these, 2.9 were patients' visits to the general practitioner's o ffice and approximately 0.7 home visits to the patient ; the remainder were telephone conversations , etc. No comparable figures are available for the approximately I 0% of the population who are insured und er the free-choice-of-doctor scheme . The population of the county is also served by a number of private special- ists representing a total of 15 different medical specialties. These specialists had a total of 56 500 office consultations excluding those in hospital out- patient departments (approximately 0.1 consultations per person per year), but they paid on ly 53 home calls to their patients. The county operates 5 general nursing homes with a total of 232 beds (the general rule, however, is that such homes are the responsibility of the nmni- cipalit ies). In addition, the county has special homes for the socially disabled with I 09 beds. The county is also responsible for the midwifery service, which has 49 county midwives organized in 7 centres (each attached to a hospital). These midwives a re based in the districts, but they assist in the delivery of their own patients within the hospitals. In addition, 13 midwives are employed directly by the obstetrical department of Aarhus Kommunehospital. Midwives assisted at approximately 9000 births and held 46 000 consultations in 1974, the latter in special prenatal clinics operated by them. With regard to occupational health, the county will probably assume respon- sibilities in this field in accordance with the act of 197 5 regarding labour protec- ti on. It intends to establish a medical clinic (with no beds) for this purpose. Psychiat ric nursing has recently come under county administrat ion . The nurses are attached to the mental hospital of the county and use it as their base of operations. The co unty does not take direct responsibility for medical transport, which is assu red by a private company tha t operates all ambu lances in accord - ance with an agreement with the county. If helicopter transport is needed, it is provided by the Royal Danish Air Force. In addition to its involvement in the health field, the county also concerns itse lf with some soc ia l services. An important feature is the county's social centre, a unit whose main function is to act as secretariat to certain State com- missions at county level. Some commissions establish disabil ity and other pensions (except for the retirement pension, which comes under the nmni- cipality) . Others deal with adopt ions, abortions, sterilization , and similar cases. In add ition the cent re gives counsel to and provides supervision for municipal socia l services. Residential institutions for child care such as orphanages are also the responsibility of the county, while similar day-care institutions are run by the municipality . A special appeal board for social affairs reviews decisions taken by municipal social services when appea ls from such decisions are made to the county. Aarhus County also runs a rehab ilitation centre with 122 beds. The clinic mainly treats alcoholics and narcotic addicts but also handles a certain number 231 of physically disabled persons, the most severely disabled being cared for in special nursing homes belonging to the State or the county. This rehabilita- tion clinic has medical, nursing , social , and support personnel and treats nearly I I 00 persons per year. In addition, the county runs a special outpatient rehabilitation evaluation clinic with medical and nursing staff, which assesses patients with regard to the possibility of giving th em occupational retraining. This section has dealt only with the health services adm.inistered directly by the county. However, the co unty is also responsible for giving advice to and supervising the municipalities and the health services under municipality jurisdiction. COUNTY PLANNING OF THE HOSPITAL SECTOR The Hospital Council is responsible for producing a hosp ital plan and presenting it to the County Council for discussion. In 1970 a survey was made of the county witl1 regard to population development , the hospital structure , hospital utilization, manpower, and hospital economy. A functional review was made for each specialty , analysing waiting lists in relation to the availab ili ty of beds and the pattern of coordination between tlie various hospitals. Using the hospital planning guide from the National Health Service as a general reference, a development plan was then drawn up specifying the number of hospitals, their size, and their role in the future hos pi ta! services for the county .0 In this work the county hospital adm.inistration consulted various directors of hos- pitals, chiefs of hospital departments and matrons, and the local branches of tlie Danish Medical Association. The local representatives of tlie State health adm.inistration - the pub lic health officers - had no formal role in the de- velopment of the hospital plan, but the county public health officer at that time was included among the doctors consulted through the local branch of the Danish Medical Association. The consultations were on an ad hoc basis , and the county hospital administration was given considerable freedom as to how much counsel they wanted to get and from whom. No consumer groups were contacted during the planning process, nor were any loca l branches of voluntary health o rga nizations involved. No assistance was given by the Danish County Council Association during the formulation of the plan. The first draft advocated the establishment of a large new hospital and the closing down of some of the smaller ones. This was not accepted, for political and financi al reasons. As a consequence, the county hosp ital director and his staff drew up a revised plan taking into consideration the guidelines given by a Apa rt from reviewing waiting lists and assessing the coverage of its health services in relation to the genera l guidelines la id down by the National Hea lth Service, the county hospital administration did not undertake any special investiga tion to stud y the need for different types of hospital services. 232 the politicians. A new pl an with less input from the medical and nursing profes- sions was adopted by the County Council in 1974. The Minist ry of the Interior still had the plan for approval in June 1976. The plan covers the period from 197 5 to 1986. The first 5 years are des- cribed in detail , while the activities for the remainin g period a re loosely sketched. No efforts had been made by I 976 to review the plan , but adjustments are made in the annual county investmen t and opera tin g budgets because of the changing financial situation from year to year. The plan divides the county into 4 hospital areas (Aarhus, Grenaa, Ran de rs , and Silkeborg). While 5 of the 15 county hospitals are already loca ted in Aarhus City, the hospital plan provides for the construction ofa new medium- sized hospital in Aarh us City . The structure of the hospital services in the coun- ty will be as fo llows: Aarhus hospital area: (a) 7 hospitals in Aarhus City: I hospital with a full range of specialties in- cluding regional ones; 2 medium-sized hospitals (of abou t 500 beds) , one with a wide range of specialties, the other with a more restricted number ; 4 smaller specialized hospitals for aftercare, rehabilitation , and men ta! diseases ; and (b) 3 smaller hospitals in other parts of the Aarhus hosp ital area ; Grenaa hospital area: 2 smaller units on ly; Randers hospital area: I medium-sized hospital with a full ran ge of specialties and I smaller unit ; and Silkeborg hospital area: I medium-sized hospital with a full range of specialties. The target for the bed complement is to be 5 .7 in 1985. Because of econ- omic difficulties, it has bee n decided to red uce the size of the new hospita! to be built in Aarhus City from 600 to 480 beds, to reduce the planned ex - pansion of Aarhus County Hospit al, and to de lay the planned ex pansion of Grenaa Hospital until after 1985. Some of the policies relating to hospi tal care included ce ntralizin g all births in special gy naeco logical/obs te trical departments. The capacity for sur- gical beds ( I. 7 per 1000) and in tern al medicin e ( 1.8) was expected to be sufficient , and further expansion of capacity would take pl ace by expan ding outpatient care. The Na tional Health Service in 1968 advised th at long-s tay (mainly ge ri - atric) ca re beds should be approximately I. I per IO00 population. In the first draft of the Aarhus County hosp it al plan a goa l of 0.9 was sugges ted. However, this figure was challenged as being too high, since many patients in hospitals cou ld be placed in nursing homes. As a result th e targe t was red uced to 0 .5 beds per 1000 for this type of ca re. 233 The former State Psychiatric Hospital (some 700 beds), an old institution in need of improvement, was taken over by Aarhus County in 1976. The hos- pital plan aims at reducing the number of beds in this institution by estab- lishing 2 psychiatric departments in general hospitals in 2 of the other 3 hospi- tal areas. High priority will be given to the establishment of new psychiatric nursing homes and the expansion of day-care facilities . With regard to intercounty cooperation, no definite regions have been defined in this part of Denmark . Nevertheless, the hospital plan proposes that the radiotherapy unit of the Aarhus County Hospital should serve neigh- bouring counties and that the neurosurgical unit in the same hospital should be discontinued when a new neurosurgical department in the neighbouring county of Aalborg starts functioning. COUNTY PLANNING OF PRIMARY CARE AND SOCIA L SERVICES The National Health Insurance Act of 1975 specified that the Social and Health Council should decide questions related to - among other things - services by ge neral practitioners and private specialists. Accordingly Aarhus County Council nominated a special committee of 15 memb ers , representing the county administration, the municipalities , and professional organiza- tions in the county. This group proposed the subdivision of the county into 28 general practitioner or primary care districts, determined the number of general practitioner posts for each of the districts , and established the local terms for the national contract of April 1976 between the Danish Medical Association and the National Board of Social Insurance. In August 1976 a plan for the development of general practitioners' services for the next IO years was initiated. The drafting will be by a special committee using the staff of the county health funds department as a sec- re ta ria t. With regard to the planning of other primary care services and of social ser- vices, the county rece ived in 1974 gu idelines from the Ministry of Social Affairs rega rding the implementation of the new law. The guidelines specified that the county should base the plan on draft plans for municipal health and social services made by each municipality in the county , adding the plans for the health and social services for which the county is itself responsible. It had also to take into consideration the State development plan for social and health services on such matters as the establishment of certain in stitutions for re- habilitation or certain highly specialized nursing homes. The plan should be redrafted every year. An ex tensive exchange of views then started between the health and social admin istrations in the county and in the different municipalities with regard to planned development fo r the period I 977 - 82. Most of the municipalities finished their work in 1975. The county added its own development plan rega rding the county social centre and those institutions (nigl1t institutions for 234 chi ldren and certain rehabilitation institutions) for which it is itself respon- sible. After acceptance by the County Council the plan was submitted to the Ministry of Social Affairs in April 1976. COUNTY LAND USE AND INFRASTRUCTURAL PLANNING The main purpose of infrastructural (or regional) planning is to produce a comprehensive integrated plan for the county , a plan to promote an economic, safe, and harmonious development of the environment and to strive for more eq ual conditions of living in the various parts of the county. It is the intention that the county plan should do this with sufficient restraint stilJ to provide for a reasonable measure of local planning as well. Within the Aarhus County Council, the Economic Council has the final say on the plan before this is submitted to the whole Council for final decision . However, the Technical and Physical Council, the central administration, and the county technical and physical administration all play important roles. As a first step, the county was divided in 1970 into 2 parts: urban and rural. In practice , this meant a delineation of the urban zones in order to pre- vent expansion of cities where this is not wanted . Subsequent expansion of the urban zones will have to be specifically agreed upon by the Ministry of the Environment. The next step in the planning process was registration of all the national sectoral plans already existing (roads , ed ucation, etc .). The municipalities were then asked to make rough estimates for infrastructural planning within their areas up to the year 2000 (with details only for the first 10-1 5 years). These were received by the coun ty in 1974. Summarizing all this information and add ing already exis ting county sectoral plans, the county then gave each municipality rough guidelines for their development for the coming 6 - 8 years (in order to ge t time to finalize the infrastructural planning proper). In 1977 the county, in consultation with the municipalities , drew up 4 alternative infrastructural plans for the rest of the century. After a public debate on these 4 alterna tives the county, in consul tation with the municipal- ities, decided on a final alternative to be submitted to the Ministry of the Environment by I January 1980. The Ministry - which has the power to change the plan - is expected to give its opinion in 1980-81. From then on, the plan will be reviewed every second year, but presumably only lesser modi- fications will be made. The infrastructural plan wiJI use as a basis the sectoral plans - such as the county hospital plan - and rev iew on ly those parts which are of importance from an overall planning point of view . IL can safe ly be assumed, for instance, that if the new hospital to be built in Aarhus was not planned for an urban area but for a rural area, the infrastructural plan would have to be given serious at- tention, and it seems doubtful that such land use would be accepted by the Ministry of the Environment. 235 A problem for overall planning in Aarhus County is the great variation in the amount of planning that has been undertaken by the different sectors (hospitals, roads, industrial development, etc.). THE MUNICIPALITY or AARHUS: ADMINISTRATIVE STRUCTURE AND HEALTH SERVICES It is convenient to study health services organization and planning at the municipality level in the muncipality of Aarhus (not to be confused with Aarhus Coun ty) . Th.is municipality has a population of approximate ly 245 000 people ( I 975), which corresponds to 44% of the total population of Aarhus County. The population density is high because of Aarhus City, the second largest town in Denmark. The average Danish municipality has somewhat less than 20 000 in- habitants and Aarhus municipality cannot therefore be considered to be typi- cal. Owing to its size it has a much larger administration and a more specialized health service organization than smaller municipalities have. Nevertheless, the duties conferred by the national legislation on the municipality of Aarhus with regard to health services are the same as for any other municipality. The central administrat ion of the municipality has an organizational structure that is very similar to the one found at county level. The City Council is composed of 31 representatives from different polit ical parties. The Council is divided into 5 subcouncils (Fig. 5), responsible for economjc affairs , traffic and utilities, area planning, health and social affrurs , and schools and sports. The day-to-day management of the municipal administration at central level is headed by a mayor, elected for 4 years and employed full-time as cruef administrator. Under hjm are 5 major administrat ive depart men ts, correspond ing to the subcouncils of the City Council. Each department has as its head a chair- man who is po!Hically elected and who serves for the same e lection period as the mayor and the City Council. The other employees of the 5 departments are nonpolitical and permanent. The subcouncil for health and social affairs supervises the correspond in g department for health and socia l affajrs with its 7 bureaux (Fig. 6), the depart- ment serving at the same time as a secretariat for the subcounci l. In order to advise the director of the department, a special coordinating council con- sisting of th e 7 bureau ch iefs and 2 of the social inspectors from a local area unit has been established . With regard to the functional responsibilities of the 7 bureaux, these do not give direct service to clients. The bureau of social affairs assists other units in legal affairs, serves as a secretariat for specia l child and youth cou ncils , takes care of public relations, and so on. The bureau of socia l medicine is staffed by medical officers and psychologists who mainly provide medical advice to other units, in particular with regard to sociopsych iatric prob lems, family coun- se lling, and the like. The bureau of pensions and health insurance coordinates the work of the 8 local area service units that deal with social pensions, health insurance, etc. The inspectorate of institutions is responsible for the planning, 236 N w --.J Fig. 5. Political and administrative organization of Aarhus Municipality I .----[ Subcou traff util ncil for ::: and ties POLITICAL -- ---- I Subcouncil for area planning ADMINISTRATIVE ' Department of traff util ic and ities I Department of area planning I CITY COUNCIL Subcouncil for economic affairs Department of economic affairs MAYOR I Subcouncil for health and social affairs Department of • health and social affairs I I Subcouncil for ols and Orts scho spor Department of schools and sports I I - N ~ Fig. 6. Administrative subdivisions of the Aarhus Municipality department of health and social affairs J_ ,--1 Bureau of social affairs t I Bureau of social medicine Client counselling I Director of health and I social affairs I Bureau of health Service (pensions) H Coordinating council l I Bureau of Inspectorate pensions and health insurance 8 local area service units Support, coordina- tion, and leadership group (SCL) of institutions l Bureau of finance Home help and home nursing Administration I Bureau of personnel building, and operation of social institutions, including superv1S1on of the nursing homes. There is a bureau of finance and a bureau of personnel. The bureau of health coordinates home nursing and home help services , care for the elderly, child dental care, public health nursing services, school health services, and the tasks of the assessment centre. It also serves as secre- tariat for a con tact group between the local branch of the Danish Medical As- sociation and the municipal department of health and social affairs. Direct service to the client is provided by local service units , the most import- ant of which are the 8 local area service units. Each of the units is directed by a support, coordination, and leadership group consisting of the chief of the office and l or 2 administrators . This group directs 4 sectors, which all work in 1 com- bined centre. The section of client counselling gives counsel to individuals and families with social problems. The service section deals with all questions re- garding pensions , child allowances, health insurance, etc. The administrative section deals with internal administrative matters, archives, and reception functions for the service unit. From the health service point of view, the most important section is the home help and home nursing section. This provides mothers' helps, home helps, and home nursing. It also decides on applications for admission to nursing homes, requests for installation of telephones for the aged, applications for places in special homes for the aged, etc. In addition to these 8 local area service units, the municipality provides school health and child dental care at various schools. The child dental care service gives free treatment to all children up to 16 years of age. Of the 54 000 eligible children in the municipality over half attend private dental clinics free of charge. The services are given by the school dental clinics , of which there are 36, staffed by 80 dentists and 115 dental assistants. The service includes 12 mobile dental assistant teams which visit each school about once a month and see each pupil 8- IO times a year to give advice on caries' prevention (proper nutrition, dental hygiene, and the use of fluorides). The municipality has 52 public health nurses for the care of children up to 15 years of age. Since these nurses work according to school districts, it is not al- ways easy for them to contact their local general practitioner or the local area ser- vice unit, since the subdivisions for these 3 types of staff are not coterminous. The public health nurse often visits the hospitals when a new baby is born to a mother from her district in order to familiarize herself with possible problems and she goes to the home immediately after the discharge of the mother from the hospi- tal. She pays regular visits during the first year, but from then on she concentrates on problem cases - including children who have problems with social adapta- tion. As part of their training , these nurses are now taught special psychosocial stimu lation techniques in child care, and they also perform neurological testing to ensure that problems are not overlooked at an early stage. The school health services are the only compulsory health services in Den- mark , and in the municipality are provided by 8 full-time school health doctors and I physiotherapist, partly assisted by the public health nurses already men- tioned. The school health service now increasingly turns its attention towards the care of problem children, reducing the number of routine checks it carries out. The trend is also towards linking the public health nurses and the school health doctors more closely with the 8 local area health service units. 239 Since there are increasing numbers of children and yo ung people with drug addiction and social maladaptation problems, the municipality has estab- lished a special service for this group, including a wide range of institutions and services: a special dental clinic for drug addicts with hepatitis, a school, a re- habilitation clinic, a social medical clinic (treating 15-20 clients per day under the direction of a doctor), a contact centre (15-20 clients per day, with the staff actively looking for clients in the streets), and different types of sheltered houses. The municipality also has special services for the elderly . With a total of approximately 29 000 persons who are 65 years or older ( 12% of the total population), the municipality employs a home nursing service with 89 nurses carry ing out some 240 000 visits per year. These nurses work from the 8 local area health service units, which some- times complicates contacts with the general practitioners, owing to the large number of practitioners in each area. However, the nurses have good contact with the home help service, which is organized in the same section of the local area service unit. Attached to the home help service are 32 supervisors and about 1450 assistants . On average, I home nurse cares for about 330 persons aged over 65 years. For patients who need permanent nursing care in an institution the mun i- cipality operates 39 general nursing homes with a total of 1814 beds (there are no day-care beds in these institutions), in addition to I special nursing home. The number of nursing-home beds corresponds to 6% of the population aged 65 years or over in the municipality. These nursing homes are all combined with dwellings for old people who can take care of themselves but who receive some service from the institution (social worker contact, meals, etc.) . In addition to these services, the municipality operates a wide range of social institutions (creches , day-care inst itutions for children, day institutions for ch ildren and youngs ters, etc.). Several physiotherapy institutes are established in the municipality. How- ever, except for physiotherapists working in the hospitals and the nursing homes, this sector of the health service is not under pub li c administrat ion. IIEALTII AND SOCIAL SERVICES PLANNING AT ML1NICIPALITY LEVEL While at national and county leve l there are severa l systems of hea lth and social services planning , the municipality level only has one, namely the health and socia l services plan . The political responsibility for the planning comes under the subcou ncil for health and social affairs , but the department of health and social affairs is, in practice , the unit that prepares the plan. Fol- lowing the guidelines provided by the Ministry of Social Affairs, one section identifies the goals and objectives, another indicates the expansion of the ser- vice and of the use of re sou rces for every year in the planning pe riod, and a third furnishes additional comments and background for the proposals in the 240 plan. To coordinate the planning there is a permanent planning group con- sisting of 5 members from 3 bureaux - the inspectorate of institutions, the bureau of health, and the bureau of social affairs. The most recent plan covers the period from 1977 to 1982. Work on it started in 1975. It was expected that the municipality would receive a decision from the Ministry of Social Affairs on the plan in November 1976. The work on the plan gave rise to numerous and productive discussions. One result was the realization that a better information system was needed to monitor the health and social services of the municipality. This in tum led to the elabora- tion of two pilot projects - both electronic data-processing systems - for home nursing and dental care. In addition , the relationship between the health service administration and service units was reviewed, in particular with regard to breaking down the tradi- tional barriers between various types of health personnel in providing care for the same groups of people. As a result of these discussions, 3 special working groups were created in the bureau of health - a home care group, a health care group, and an administrative group. These groups carried out extensive reviews of the present and future service components in the 3 areas, forwarding their conclusions and advice to the 5-man planning group. One of the more interesting proposals is that child dental services should be increased by a third over a 5-year period, with particular stress on dental care assistants and their preventive work. The number of public health nurses would only be increased in proportion with the population, since it was hoped to utilize the existing personnel more efficiently by concentrating on active care at the expense of some of the mass examinations of schoolchildren . The same wou ld apply to the school health doctors. The plan foresees an expansion of nursing home services by an increase in the number of beds to cover 7% of the population aged 65 years or over at the end of the 5-year planning period. It also includes the establishment of day- care beds in nursing homes to a total of some 70 by the end of the 5 years. The number of home nurses would increase by some 27%, each nurse being given responsibility for, on average, 270 persons aged 65 years or over. During the elaboration of the plan the municipality had in mind an invest- ment ceiling, since the State sets a maximum ceiling for the funds that each municipality can borrow to finance its building programme, just as it reim- burses 50% of what it considers to be a reasonable opera ting budget for the dif- ferent types of service unit ( e.g., nursing homes). The municipality therefore had to keep an eye on staffing norms and operating budgets for health institutions and health services, in order not to create an undue budget deficit. In addition to the annual sectoral plans for the health and social services, the municipality must also prepare annual investment and operating budgets . The investment plan covers 3 years at a time and is renewed every year. The plan for the financial year starting in April must be submitted to the County Council in June of the preceding year. After acceptance in the Council, the budget is sent on 1 July to the County (for information only) and to the Min- istry of the Interior (from which it is forwarded to the Ministry of Finance for approval). The municipality gets approval from the Ministry of Finance before the end of the year. 241 The operating budget of the municipality at the moment covers only I year at a time, but this will be altered to 3 years in the near future. When the sectoral plan for the health and social services is sent to the Min- istry of Social Affairs the decisions of that Ministry are binding as far as the service content goes. The corresponding financial requirements are not binding in the sectoral plan but only in the budget submitted to the other two minis- tries mentioned above. The municipality has no influence over the State and county health ser- vices operating within its borders (hospitals, mental health, general practi- tioners, etc.), although it can of course obtain copies of the plans of the coun- ties and the State. COMMENTS Like other European countries, Denmark enjoys a high standard of living, shows impressive figures on the health status of its inhabitants, has an exten- sive array of health institutions, and possesses a large body of health man- power. In general terms, therefore, Denmark can be said to have reached a level where the most basic needs for health care have been covered. Furthermore, owing to its short geographical distances, fairly extensive decentralization, and a financial system that has put all citizens on an equal footing with regard to access to medical care, Denmark has also managed to ensure a relatively fair distribution of its health services among its inhabitants. However, satisfaction with services in any given country is not usually measured in absolute and objective terms, so that neither the Danish population at large nor those responsible for the health services regard the services as being problem-free. The problems can be divided into two main groups: service and economic. From the health service point of view the increasing number of elderly persons (with chronic and often incurable diseases), of seriously injured and crippled accident victims, and of socially maladjusted people ( with complex somatic, psychiatric , or social disturbances) probably represents the major problem. These groups frequently have in common the need for help from various service units and different personnel, but it is often difficult to determine how much sophisticated treatment really is needed for them. There is a growing understanding that more effort must be given to prevention in the overall strategy for health, but effective prevention often includes very complex interventions, not only in the health system but also in the basic structure of society and in the behaviour of the individual citizen. This development coincides with an accelerating demand for health services in the middle of a particularly difficult period for the national econ- omy. The search for less expensive ways of solving health problems comes at a time when the traditional role of some health professions - that of the physicians in particular - is being challenged by other professional groups and by the politicians, who call for a broader view and for other priorities. 242 As a consequence , cooperation between different units in the health ser- vice and alternative methods of prevention and care emerge as major problems for the Danish health services. Important factors in determining the success or failure of this development will be: (a) how well the individual service units - both operational and admin- istrative - know their role, work according to the overall policy guidelines, and collaborate effectively with other units ; (b) how effective and appropriate the search is for better methods of health services and health services organization ; (c) whether the planning system is capable of converting national health policy decisions into realistic, practical, and effective working guidelines for health service units and health personnel at all levels ; and (cl) how well the health planning and health service system fits into the national economy and national development in general. With regard to the first of these factors, the Danish health services have not developed according to an overall master plan but somewhat haphazardly. The State, voluntary organizations, municipalities , individuals of certain health professions (physicians, dentists, and physiotherapists in particular) have at different times established new service units or introduced new categories of service, often without adequate analysis of the role a unit or category should have and of its relationship to other units or categories. This trend now seems to have changed and a pattern has slowly been emerging of services divided into three major groups according to their com- plexity and the size of population a unit should handle. These groups are the local health services, the county health services, and the intercounty/national services. This basic structure of the health services seems to have many advantages. It affords the possibility of identifying more clearly the functional role of every unit and it puts in focus the extent of cooperation needed between units on the same level and between different levels. If the geographical areas of responsibility are clearly indicated, it provides a basis for developing a region- alized health service system in which the functional role, the geographical responsibility, and the administrative dependence of each unit are clearly defined. This kind of system facilitates day-to-day cooperation in patient care between the various units and lays down the basic structure needed for ef- fective administrative coordination of the system as a whole. However, although a promising trend in the right direction has been evi- dent, particularly during the 1970s, several deficiencies still have to be overcome. There are as yet no clear guidelines as to which health services - if any - are so rare or so special that they should be provided in one place only in Denmark ; nor is there a decision as to whether such services should be given at one place only or spread around - for instance at various university hospitals.0 0 Denmark has 3 universities with medicaJ faculties . The one in Copenhagen has 3 clinical medical schools. Each of the 5 medical schools is attached to a large highly specialized hospital. 243 Owing to the limited size of Danish counties - some 350 000 inhabitants each on average - it is clear that certain hospital services (such as neurosurgery and cancer radiotherapy) cannot be provided in a rational way for each individ- ual county. International experience indicates that a population base of about 1 million people - corresponding on average to 3 Danish counties - is a rea- sonable size for such cooperation. Although some counties have started co- operating for certain types of heal th service, it would seem that a more precise delineation of geographical areas of such cooperation (health regions, each comprising a number of counties) and a precise definition of which health services this cooperation should include (regional health services) would create a clearer, firmer, and more effective basis for intercounty cooperation. While the county definitely seems an appropriate unit for coordination of the remaining (major) part of the hospital services, it could be questioned whether the midwifery services should not be part of local (municipality) services, in particular because of the need for close cooperation with the pub- lic health nurses (who take over the nursing responsibility from the midwife after the delivery) . Owing to the fact that the main provider of medical transport in Den- mark is a private firm, the public health authorities have not taken a very active role in this sector in the past. It would seem, however, that the county should be the level most suited for taking on the overall responsibility (but not necessarily the operational one) for such services. At present general practitioner and private specialist services are the re- sponsibility of the county. While the need for applying a common yardstick to medical specialist services given in hospitals and by private specialists makes such a choice logical , it would appear that the general practitioner is firmly established as one of the most important providers - if not the most im- portant - of primary care services. Today it is recognized that the Danish municipalities should have responsibility for most primary care and social services - for home nursing, nursing homes, public health nursing, school health, dental care, and some rehabilitation. It would seem that one of the most important elements - the general practitioner services - is lacking in this picture. It is tempting to believe that the present situation - in which the general practitioner has a contract with the county and not with the muni- cipality - tends to make the general practitioner a less active member of the primary health care team than would be desirable. On the other hand, the present structure permits close cooperation between general practitioners, specialists, and hospitals. Another important deficiency in the present system is the failure to in- clude physiotherapy among the primary care services that come within the munjcipality's general responsibilities. Care of the elderly and the handicapped does, but responsibility for physiotherapy under the Health Security Act is the responsibility of the counties. An important aspect of coordination is the geographical one of service responsibility for each unit in the health services . There can be no doubt that different health service units (a health centre, a general practitioner, a private physiotherapist, etc.) would cooperate more if they dealt regularly with the same group of patients and the same colleagues. This is easier to organize if 244 each service unit has a clearly defined population area and if this area has as far as possible identical boundaries with those of the collaborating health service units . From the population point of view the existence of clearly identifiable health service areas greatly facilitates contact with the health services. The present situation in Denmark appears to be unsatisfactory in this respect. There is no congruence between catchment areas for hospitals and districts for general practitioners, public health nurses, home nursing services, midwifery services, and nursing homes. However, an interesting start has re- cently been made on coordinating some of these services, as is evidenced by the subdivision at local level of the municipality of Aarhus into eight local areas, each served by a team of health and social workers. This is a good starting- point for creating better defined geographical areas for the provision of local health services to the community . It would seem that considerable thought should be given to how this principle could be further developed in order to make the areas of the general practitioner services, the specialist services, oc- cupational health, the midwifery services, etc., coterminous with the local health and social areas already established. An effort should also be made to organize physiotherapy services for the same areas . To what extent the different services should be provided from one health centre or not would depend on the local population distribution, the geo- graphical characteristics, and the already existing pattern of services in the community. So far Denmark has not made any furn commitment to the es- tablishment of comprehensive health centres. Quite a number of physicians work in group practices, and the municipalities are beginning to establish basic service centres (like the eight service centres in Aarhus Municipality) for most of the basic social and health services at present under their respon- sibility. However, there are still few examples of comprehensive units as a private initiative providing the whole range of basic health services. It seems clear that Denmark has decided to use the general practitioner and the public health nurse as cornerstones in the further development of community services, occupational health services, care of the elderly, etc . It would appear, therefore, that the time has come to study which organiza- tional model could best provide such comprehensive services for the com- munity and whether the establishment of comprehensive health and social centres in selected areas should become an integral part of the health services structure. While a clearer and better integrated delineation of geographical responsi- bility will help to provide a clear-cut structure for cooperation among health service units, the decisive factor in promoting cooperation and an efficient ser- vice is whether there exist clear and effective guidelines for cooperation and the distribution of responsibilities throughout the service and whether the per- sonnel are motivated accordingly. A retrospective look at the Danish health services reveals a long-term trend towards the assumption by the public sector of more and more responsibility for the services. While this responsibility was previously the State's, legislation passed during the last 6-7 years has delegated to the county and municipal authorities a steadily increasing responsibility for the operation and planning of many of the health services. This development has been gradual, and it has 245 been widely accepted by the Danish population . Although there are still import- ant private enterprise components in the Danish health services, they tend to be more and more coordinated with - and supervised by - the public services. The principle emerging from this legislation is the relinquishment by the State of responsibility for provision of services to the local authorities, and the retention of only a more general overall control of development , including central supervision of local authorities and coordination of the use of re- sources by the health and other sectors of society. While the municipalities will be responsible for the basic health services, the counties will retain services for larger population areas ; in addition the counties will coordinate municipal health work. There are indications that this coordinating role is not always as strong in practice as was intended in the legislation. As part of this develop- ment , important changes have taken place in Denmark in the financing of the health services, the administrative responsibility for individual service units, and the planning system. Some details are still lacking to make the organizational structure com- plete. Although the State has handed the psychiatric hospitals over to the counties , it still retains the hospitals for the mentally retarded, certain rehabili- tation units, and the University Hospital , Copenhagen. A special council has been created to coordinate hospital policy for all hospitals in the counties and municipalities of the Copenhagen area. Nevertheless it would appear that the State ownership of one hospital could create unnecessary problems for the development of a consistent hospital policy. Although the new development tends to diminish the role of the State by removing its service responsibilities, it would seem that the development of an overall health services policy and the coordination of resources (both between ministries and between ministries and counties) will face the State with very considerable problems. ls the existing State administration equipped to cope with this? At present four ministries have direct responsibility in the health field - the Ministry of the Interior , the Ministry of Social Affairs, the Ministry of Education, and the Ministry of Labour. Although some coordination is taking place, in particular between the Ministry of the Interior and the Ministry of Social Affairs, there are indications that the present division of respon- sibility does create problems in the formulation of a well-balanced health services development policy. This has to be expected when , for instance, two ministries (Interior and Education) have responsibilities in formulating hospital policy and the major responsibility for inpatient and outpatient care is split between two ministries (Interior and Social Affairs) . It is tempting to believe, therefore, that a better concentration of responsibility for health services administration at ministerial level would help the State to achieve a better integrated and more coherent health service policy. The need to cross the traditional barriers of health services so as to promote a more comprehensive approach to a national strategy for health should also raise the question whether the present counselling service at ministerial level - with separate councils for the hospital sector , primary care, social services, etc. - should be replaced by a more unified structure. In this connexion, the absence of a formalized structure for professional counselling at county level should be noted ; this , too , needs reviewing in the light of national experience. 246 The National Health Service at present occupies a key position in coordina- tion at the subministerial level , since the legislation specifies that ministries and national boards should seek its advice on health and health services problems. Although the National Health Service has considerable resources at its disposal, it would seem that the present lack of a planning unit could become a weakness in the future as more of the problems of the State health authorities will concern planning and evaluation, including health economics. The National Board of Social Insurance and the National Board of Social Welfare have important administrative responsibilities for general practitioner services, home nursing services, services for the mentally retarded , etc. This makes it especially necessary to ensure close cooperation between these two boards and the National Health Service. At the county level the present sharp division between the hospital services and other health and social services - a division found all the way up through the administration to the county councils - seems to constitute an artificial barrier to close cooperation between the hospitals and the other health ser- vices. There is general agreement that in many countries - not only Den- mark - the hospital services have developed much too independently, with detrimental effects both on the continued care of the patient and on the efficient use of resources. As long as the hospital sector is regarded as being separate from the rest of the health services, the hospitals tend to become too self-centred and to judge capacity and performance on the basis of their in- ternal needs rather than on the services they render to the community outside. Examples can be found to support the view that this is also happening in Den- mark. It would appear that a more unified administrative and political organ- izational structure at county level could facilitate the efforts towards a better coordinated county health service. The State is at the moment represented at local level by the public health officers. However, their duties tend to be mostly environmental hygiene, micro- biological surveillance, and similar tasks, although in some cases they have taken great interest in the problems of primary care (not as much in those of hospital care) . At the moment the public health officer is in general not regarded by the counties as a real part of the county health administration , and his contribution to county and municipality health services, planning, and administration is fragmentary and ofte n poorly defined, in spite of the rather important advisory role the law gives him. Furthermore, the geographical areas of responsibility for the individual public health officers have not until now been coterminous with the other health service unit areas (hospital areas, general practitioner areas, etc.). According to the 1973 act public health officers should work in so-called public health institutions covering each county. By September 1977 such insti- tutions had been established in 7 of the 14 counties. The general impression is that the influence of the public health officer is gradually becoming weaker. The consequent lack of public health input into the county and the municipality health administrations would seem to be an important weakness in the present system. The public health officer , with his background in medicine and his training in public health administration, is particularly well suited to playing a more active role in health services admin- istration and planning at county and municipality level. 247 Three different aspects of Danish experience in health planning invite comments: the health planning system as such, the research and evaluation input into the planning process , and the information system. While Danish health services traditionally did not develop in accordance with any definite system of health planning, the country has enacted several important pieces of health planning legislation from 1969 onwards. These reforms have already had a far-reaching impact on the organization of Danish health services and led to a better understanding both of the need for, and the practical difficulties in- volved in , a more planned approach in health services development. However, there is still a considerable distance to cover before Denmark can be said to have a health planning system that serves medical, administrative, and econ- omic needs at the national , county, and local level. Some parts of the health services are as yet, for all practical purposes, not included in any regular public health planning; physiotherapy, occupa- tional health, dental health services for adults, private specialist services, and medical transport would have to be included in this category. Incorporating them into any one of the existing health planning activities would not seem to present too great difficulties. Most of the planning systems still seem to be too much resource-oriented, at the expense of the functional aspects of the services. Hospital plans in particu- lar seem to build largely on the past functional role of the units without any extensive analysis of its possible weaknesses or of the possibility of achieving improved results (whether with regard to effectiveness or efficiency) by a change in strategy. One reason for this could be that the planning systems and guidelines do not force the planners and decision makers to set systematic objectives and targets in relation to previously determined overall goals. The planning process therefore - although somewhat better in the primary care and social services sector than, for instance, in the hospital sector - seems in most cases to lead the planners and decision makers fairly rapidly past the dif- ficult process of functional evaluation to the familiar terrain of resource calculation. In this respect it would seem important that criteria for evaluation of the proposed plans of action are almost universally lacking. The request for an in- creased number of hospital beds, for instance, is not linked to an assessment of the quantity and quality of national medical needs but only in general to waiting lists or estimates. Since the criteria for evaluating the proposed change are not made explicit at the time the plan is submitted, decision makers are in a difficult position when they have to decide on such questions or review the appropriateness of similar decisions in the past. Closely linked to this problem is the fact that almost all the planning sys- tems used in the health services present only one plan. This does not force the planners to think seriously of alternative ways of solving the problems, and it leaves the decision makers with little choice and less insight into the prob- lems. Nor do the present health planning systems in general give a clear indica- tion of priorities. This also tends to make the situation more difficult for the decision makers. However, the most important problem is the present fragmentation of health planning, the result of the number of different planning systems and 248 their insufficient coordination . At present there are separate planning systems for the hospital services , the general practitioner services , other primary care and social services, services for the men tally retarded, services for the physically handicapped, etc. The different health plans are at present issued separately; they are worked out by various administrations, cover different planning periods, and are often decided at irregular time intervals. It is sufficient in this respect to point to the differences in the annual planning system for primary care and social services on the one hand and the hospital planning system - still in its first 7-year phase - on the other. This creates the danger that func- tional and resource coordination between the service units in different plans is not as well integrated as it should be. For instance , the general practitioner and private specialist services are key factors in the rational planning both of hospital services and of municipal health services, but they are now planned by separate bodies. The full potential benefit of the available resources cannot be achieved when information regarding closely related services is lacking at the time the plan is decided upon. In practice the county council now may have to decide on the construction of a new hospital without being aware that neces- sary investments in the primary care sector will have to be reduced. The central health authorities are, of course , aware of this problem and have taken steps to solve it. True, there is a committee at county level (2 or 3 representatives from the councils for hospitals and for primary care and social affairs, in addi- tion to a public health officer) with the duty to provide coordination (planning included) for hospital services and primary care. However , the county is not required to solicit the view of this group , which does not give it the strongest of mandates . In this respect it also seems that certain administrative procedures make things more difficult for local planners than would seem desirable. An important factor in primary care and social service planning is that the municipalities should know the reimbursement rates for units of service that will be applied in any given year by the State. At present this information is available at local level so late that the municipalities are forced to plan on the basis of their own estimates - and make subsequent extensive corrections when the State has finally made its position known . The present multitude , disparity, and insufficient coverage of health planning systems prevent a truly broad comprehensive approach to the health ser- vice, its problems, its use of resources, and the alternatives it might employ - whether at national, county, or muncipality level. It would seem, however, that merging the present systems and filling in the gaps to make a coordinated genera l health planning system covering all aspects of public sector involvement shou ld not be too difficult from a purely technical point of view, given the ex tensive experience now available. Most probably the readjustment of ad- ministrative responsibilities and procedures would present the major stumbling- block. It would seem that the advantages would , in the long run , compensate for the transitional difficulties. An important aspect of health planning is health manpower planning. Den- mark enjoys, by and large , a large and well-trained body of health manpower. However, the rapidly increasing demand for specialists occasioned by medical and technological advances - whether medical, technical, or nursing - makes 249 new calls on the educational system, which has to provide the right amount of manpower with the right education and training at the right time. At the moment the planning systems used in the Danish health service neither cover the necessary professional groups nor give enough in formation to characterize their training needs . A more extensive effort would seem to be called for, and this alone should bring about a closer coordination of present health planning efforts. With regard to coordination between health services planning and the plan- ning of other sectors and of socioeconomic planning in general, Denmark has made a considerable effort with a regional planning system and a new public administration budgeting system now in the making. It would seem that the needs of coordination in area planning and budgetary coordination will be well taken care of by these innovations, although the lack of annual revisions of re- gional plans creates problems. However, the reciprocal influence of health sector activities and health- related activities - positive or negative - in other sectors of society (urban- ization, housing, road traffic, nutrition, etc.) is a matter of great complexity. All too often the health sector tends to make protests against health-threatening developments in other sectors that are too vague and general , particularly if voiced when the planning is already well advanced. For such protests to be taken into consideration Jong and persistent pressure by public health officers of high competence and authority is necessary. This connects directly with what has been said earlier about the need for ensuring that the public health officers have a more permanent and powerful sphere of influence in the county and municipal health administrations and in the general planning structures at those levels. Of paramount importance to the planning effort is the performance of the information system. Three aspects of this system are relevant : the availability of data (sources, types, technical data-handling), the analytical evaluation, and the feedback from this evaluation to the planning process. In Denmark the availability of data for planning purposes is good in some respects but less satisfactory in others. The available demographic data on the population, including forecasts for the future, contain the information needed for health planning purposes, but there does not exist in Denmark - nor for that matter in most other countries - much information on the prevalence of disease or accident-producing or accident-predisposing factors. No general surveys to measure the prevalence are carried out. Some surveys on particular problems - e.g., smoking habits - are undertaken from time to time, but they tend to be national in character and not always suited for planning local intervention programmes. More information could be made available for health planning purposes by a more systematic collection of such data through the health information sys- tems already existing and collaboration with other sectors and their information systems. Examples are a more intensive road accident programme (adapta- tion of present information systems used by the police, the road authorities, and the health services could provide meaningful data for local application) and a planned occupational health programme (similar coordination could be estab- lished between the industries, the Ministry of Labour, and the health services). 250 Information regarding the health status of the population is restricted to the incidence of notifiable diseases, hospital discharge statistics, and death certificates. Consequently very little is known about the disease spectrum treated by the primary health services in the different planning areas, and the possibility of collecting such data for planning purposes from the information given by general practitioners and private specialists to the county social in- surance office should be explored. Plans already exist to expand the hospital discharge statistical system to include (in 2-3 years) outpatient activities of the hospitals, which will improve the information system considerably. Information on outcomes is generally insufficient. Disability data received by the social insurance offices are a potentially valuable source of information which at present is not used for health planning purposes. With regard to information on health services resources, general data on the number of personnel, institutions, their bed components, etc., are avail- able in routine statistics. The new budgetary system planned for the public sector will make possible much more detailed studies than before on the cost of items of service, but it will not in itself provide a sufficient basis for a com- prehensive view of the functional aspects of the health services. A major problem at the moment is the difficulty of bringing together in- formation on health problems, the action taken to overcome them, the results obtained , and the resources spent. This is owing partly to lack of sufficient de- tail in the data, partly to lack of any information at all , but mostly to Jack of a common link between the data. Since a personal identification number (for electronic data-processing purposes) has already been given to every citizen, a means of linking informa- tion on individuals from different sources already exists. The possibility of such linkage of data is being introduced into the new hospital information sys- tem and the use of resources from different units on a specific activity can also be determined. If a similar system was developed for the primary care services, very interesting analyses could be made for planning purposes of the relative utilization of different health services and of their results in relation to various medical problems. At present the development of the reporting systems has not come to the point, in Denmark, where this would be possible , but the possibil- ity can easily be foreseen for the fairly near future . Such linkage of informa- tion presents considerable problems with regard to confidentiality and there is as yet no definite plan to carry out such studies in Denmark. The organization of data collection for the health services in Denmark is at present divided into two main streams : one going to the National Health Ser- vice (hospital data, birth and death certificates, infectious diseases, cancer, maternal and child health, abortions, etc.), the other going to the Central Bureau of Statistics (information on social and certain primary care activities) . To what extent this separation of the data streams (which includes separate publications) leads to difficulties from the management point of view is not clear. More important is whether the analytical evaluation of the data takes into due consideration all the pertinent information . At the national level this should be well taken care of by the special statistical unit in the National Healt h Service, which cooperates closely with other epidemiological units such as the cancer registry, the Institute for Clinical Epidemiology, and the Institute 251 for Social Medicine . At county and municipality level the situation is less favourable, since there are no epidemiological experts within the regular ad- ministrative structure. Here again is a case for a stronger role for the public health officers, whose role at present seems to be weakening. The crucial element is to what extent critical evaluation is really per- formed and whether research is started when such problems are discovered as cannot be solved on the basis of the available information alone. The statistical unit of the National Health Service has undertaken special studies - one being on the need for hospital beds in the Copenhagen area - but in general its routine work takes up too much time to leave it with much capacity for special studies. The possibility of furnishing decision making with a firm basis of opera- tional research has considerably increased in recent years. The establishment of the Social Research Institute and , later, the Hospital Research Institute will give the Danish health services a good opportunity to obtain the necessary re- search back-up for its development. Both institutes have made a promising start and good contacts are being established , inter alia with the clinical and basic research units of the universities. One disturbing question remains : has the decentralization of decision making now gone so far that the system can no longer be subject to the neces- sary control at the national level? The present system leaves the central auth- orities with very little real power since economic responsibility has to a large extent been transferred to the counties (and to a lesser degree to the muni- cipalities) , with regard both to capital investment and to operating costs. This leaves the State with a rather vague mandate - as shown both by the refusal of the counties in some instances to pay heed to the opinion of the ministries and by a certain hesitation on the part of the ministries to commit themselves to a clear confrontation with the local authorities. The ministries also lack a strong mandate to enforce their views about manpower planning, for instance in en- suring a fair distribution among counties of scarce resources of trained man- power. The present system relies more on voluntary cooperation by the parties involved. It will be very interesting to see whether a decision-making system based so broadly upon voluntary collaboration and a "soft approach" can function effectively , especially in times of strain . The test will come if the economic or manpower conditions of the country develop in such a way that the local administ rations are called upon to show solidarity and restraint to a larger degree than they feel justified. If the system survives that test, it will be a con- siderable credit to the self-discipline of the administrative and political system of the country. 252 WHO publications may be obtained, direct or through booksellers, from : ALGERIA: SociCtC Nationalc d'Edition ct de Diffusion. 3 bd Zirout LEBANON: The Levant Distributors Co. S.A.R.L., Box t 181 Youccf, ALGIERS Makdassi Street, Hanna Bldg, BEIRUT ' ARGENTINA: Carlos Hirsch SRL, Florida 165, Galerias Giicmes, LUXEMBOURG: Librairic du Centre, 49 bd Royal, I VXE MBOU RO Escritorio 453 /465, BUENOS AIRES MALAYSIA : The WHO Programme Coordinator , Room 1004 AUSTRALIA: Mall Order Sales: Australian Government Pub- Fitzpatrick Building , Jalan Raja C hulan, K UALA L u M rU R 05- 0i lishing Service Book"hn.- P A _l3c--:_ Q,t r.,NRERR.A A .C .T. - Jubilee (Book) Store Lid, 97 Jalan Tuanku A b.Jul Ra hma n, - - - ~- ·· ., ___ _ • ' .. .......... ni_nA - P~rrv 'q Uook Center, u ons ana 1nqu1ry Centres al: 113- 115 London Circuit, C AN• BERRA CITY A.C .T. 2600; Shop 42, The Valley Centre, BRISBANE, Queensland 4000; 347 Swanston Street, MELBOURNE VIC 3000; 309 Pitt Street, SYDNEY N.S.W. 2000; Ml Newman House, 200 St. George's Terrace, PERTH WA 6000; Industry H ouse , 12 Pirie Street , ADELAIDE SA 5000; 156-162 Macquarie Street. Hou.RT TAS 7000 - Hunter Publica tions, 58A Gipps Street . COLLINGWOOD VI C 3066 .... -· ····· - · · __ _ • ' ' '' ·• ~ l... ALA LL' MP UR MEXICO: La Prcnsa Mectica Mcxicana , Ed1ciones C1ent ificas . Pasco de las Facullades 26, Apt. Postal 20-413, MEX ICO C ITY 20, D.F. MONGOLIA: see India, WHO Regional 1 ,111ce MOROCCO : Editions La Porte, 281 avenu, Mohammed V RABAT MOZAMBIQUE : INLD , Caixa Postal 4030, M.u>UTO NEPAL : su India , WHO Regional Ollie, AUSTRIA: Gero ld & Co., Graben 31, 101 I VIENNA I BANGLADESH: The WHO Programme Coordinator, G .P .O . Box 250, DACCA 5 - The Association of Vo luntary Agencies, P .O. Box 5045. DACCA 5 NETHERLANDS : N . V. Martinus N i11,o ff 's Boc .t handel en Uitgevers Maatschappjj, Lange Voorhou • 9, TH E HAGlJ£ 2000 NEW ZEALAND : Government Printing Office Mulgrave Street Private Bag, WELLINGTON I, Go1Jrrnmen1 Boolnhoos at _'. Rutland Street , P.O . Box 5344 , AUCKLA o 130 Ox ord Terrace, BELGI UM: Otlice interna tio nal de Librairie, 30 avenue Mamix, P .O. Box 1721, C HRISTCHURCH ; Alma rcei, p o. Box 857 . 1050 BRUSSE LS - S ubscrlp//ons I O World Heallh only: Jea n de HAMILTON; Princes Street , P .O. Box I 104 D UNEDIN _ R . Hill Lannoy, 202 avenue du Roi, 1060 BRUSSELS & Son, Ltd , Idea l House, C nr G illies A venue&. Eden S1. , New- BRAZlL : Biblio teca Regional de Medicina OMS/OPS, Unidade market, AUCKLAND I de Venda de PublicacOCs, Caixa Posta l 20.381 , Vila Clemen- N IGERIA : University Bookshop Nigen Ltd, University of lino, 04023 Slo PAULO , S.P. Ibadan , IBADAN - G. 0. Odaluwa Publishers & Booksellers Co. BURMA : see India, WHO Regional Office 9 Hausa Road, SAPELE, BENDEL STATE CANADA: Single and bulk copies of lndl~idual publicallons ( not NORWAY : Johan Grundl Tanum Bokhandel Karl Johansgt. 43 . subscriptions) Canadian Public Health Associatio n, 1335 1010 OSLO I Carling Avenue . Suite 210, OTTAWA, Ont. KIZ SNS. Sub- PAKISTAN: Mirza Book Agency, 65 Shah1a h- E- Ouaid-E-Aza m . scrip/ions: S 11bscrip1ion orders , accompanied by cheque made ou/ P .O . Box 729, LAHORE 3 to /he Royal Bank o f Canada. OTTAWA, Account World Health PAPUA NEW GUINEA: WHO Programme Coordinato r , p 0 . Organization, should be sen/ 10 the Wo rld Health Organi?.ation , Box 5896, BOR0KO P .O . Box 1800, Postal Station D, OTTAWA. Ont. KtP 5R5 . Cor- PHILIPPINES: World Health O rganization, 1tegionat Office for respnndence concerning subscrlplions should be addresstd 10 1he the Western Pacific, P.O. Box 2932, MA MLA - The Modern Book World Health Organization, Distribution and Sales, 1211 GENEVA Company Inc ., P .O. Box 632, 926 Rizal Avenue, MANILA 27 , Switzerland POLAND : Sktadnica Ksicgarska, ul Mazow1ecka 9, 00052 WARSAW CHI.NA : China National Publicatio ns Impo rt Corpora tio n , P .O. (exceo1 periodicals) - BKWZ Ruch. ul Wronia 23. 00840 Box: 88, PEKING WARSAW ( periodicals only ) COLOMBIA: Distrilibros Ltd , Pio Alfonso Garcia , Carrera 4a, PORTUGAL : Livra ria Rodrigues, 186 Rua do Ouro, LlseoN 2 Nos 36-119, C ARTAGEN A SIERRA LEONE : Njala University College Bookshop (University CZECHOSLOVAKIA: Arda, Ve Srneckach 30, 11127 PRAGUE 1 of Sierra Leone). Private Mail Ba g, FRE11owN D ENMARK : Einar Munksgaard, Ltd, Nerrcgade 6, I 164 COPEN• SINGAPORE : The WHO ProRra mme Coordin . tor 144 Moulmem HAGEN K Road. G.P.O. Box 3457, SINGAPORE I - Sdec1 Books (Pte) l td , ECUADOR: Libreria Cientiflca S.A. , P .O. Box: 362, Luque 223. 215 Tanglin Shopping Centre, 2/F, 19 Tanglin Road, ,'INGA- GUA YAQUI L PORE I 0 EGYPT: Nabaa El Fikr Bookshop. 55 Saad Zagbloul Street, SOUTH AFRICA: Van Schaik's Bookstore (Ply) Ltd, P .O Box ALEXANDRIA 724, 268 C hurch Stree t, PRETORIA 0001 EL SALVADOR : Llbrcria Estudiantil , Edificio Comercial B No 3, SPAlN: Comercial Atheneum S.A •• Conscjo de C iento 130-136, Avenida Libcrtad . SAN SALVADOR BARCELONA 15 : General Moscard6 29, MADMID 20 - Libreria FIJI : The WHO Programme Coordinator, P .O. Box J 13, SUVA Diaz de Santos, Lagasca 95, MADRID 6; Balmes 417 \ 419, FINLAND: Akateeminen Kirjakauppa, Keskuskatu 2, 00101 BARCELONA 6 HELSINKI JO SRI LANKA : see India. WHO Regional Office FRANCE: Librairie Arnette, 2 rue Casimir•Oelavigne, 75006 PARIS SWEDEN: Aktiebolaget C. E. Fritzes Kung!. Hovbokhandel, GERMAN DEMOCRATIC REPUBLIC : Buchbaus Leipzig, Post• Regeringsga tan 12, 103 27 STOCKHOLM fach 140, 701 LEtPZI0 SWITZERLAND : Medizinischer Verlag Hans Huber, Lioggass GERMANY. FEDERAL REPUBLIC OF : Govi-Verlag GmbH, Strasse 76, 3012 BERNE 9 Ginnheimerstrassc 20 ; Postfach 5360, 6236 EscHBORN _ W . E . SYRlAN ARAB REPUBLIC: M . Farras Kekhia, P .O. Box Saarbach , Postfach 101 6 10, Follerstrassc 2 , 5 COLOGNE 1 _ Alex . No . 522 1, ALEPPO Horn, Spiegelgassc 9, Postfach 3340, 6200 WIESBADEN THAILAND: su India. WHO Regional Office GREECE : G. C. Eleftheroudakis S.A ., Librairie internat ionale, TUNISIA : Socittt Tunisienne de Diffusion, 5 avenue de Carthage , rue Nikis 4, ATHENS (T. 126) TUNIS HAITI : Max Bouchereau, Librairie "A la Caravelle", Bo ite postale TURKEY : Hasct Kitapcvi, 469 lstik lal Caddesi, Beyoglu ISTANBUL 111•8, PORT·AU·PRINCE UNITED KINGDOM: H. M . Stationery Office: 49 High Holbom. HONG KONG : Hong Kong Government Info rmation Services, LONDON WC I V 6HB ; J3a Castle Street, EDINBURGH EH2 JAR ; &;aconsfield H o use, 6th Floor, Queen's Road, Central, VICTORIA 41 The Hayes, C ARDIFF CFI IJW ; 80 C hichester Street . BELFASr H UNGARY: Kullura, P.O.8. 149, BUDAPEST 62 _ Akademlal BT! 4JY: Brazennooe Street, MANCHESTER M60 SAS · 258 Broad KQnyvesbolt, VAci utca 22, BUDAPEST V Street, BIR.MI NO HAM Bl 2HE; Southey House, Wine Street, JCELANO: Snacbjern J onsson & Co., P .O. Box 1131 , Hafnar- BRISTOL BS I 2BQ. All mall ordus should be sent lo P .O. Box 569 . s1raeti 9, REYKJAVIK LONDON SEI 9 NH INDIA: WHO Regional Office for So uth-East Asia . World Health UNITED STATES OF AMERICA: S ingle and bulk cout,s of House , lndraprastha Es tate. Rina Road, NEw DELHI 110002 _ individual publications (no, subscrlpllons ) . WHO Publications Oxford Book & Stationery Co., Scindia House, NEW DELHI Centre USA, 49 Sheridan Avenue, ALBANY, NY 12210. Sub- 110000; 17 Park Stree1, CALCUTTA 700016 (S ub-Agenl) scriptlons: Subscription orders, accompanied by check made out INDONESIA: M /s Kalma n Book Service Ltd, Jin . Cikini Raya lo lhe Chemical Bank , New York, Account World Hea lth No. 63, P .O . Box 3105/Jkt., JAX.A.RTA Organization, should be sen/ 10 lhe World Hea lth Organiz.ation. IRAN : Iranian Ama lgama ted Distribution Agency, J51 Khiaban P .O. Box 5284, C hurch Street Station, NEw YORK, NY 10249. Soraya, TEHERAN Correspondence concerning subscrlpllons should be addresud 10 IRAQ : Ministry of Informa tion. National Ho use for Publishing , lhe World Hea lth Organization, Distribution and Sales, 1211 Distributing and Advertising, BAGHDAD GENEVA 27, Switzerland. Pub/lea/Ions are also available from 1he IRELAND : The Stat io nery Office, D UBLIN 4 United Nations Bo~ksbop, NEW Youc, NY 10017 ( relaf/ only) ISRAEL: Heiliaer & Co .• 3 Nathan Strauss Street, JERUSALEM USSR: For readers In the USSR requiring Russian edl1lon.r : Korn- ITALY: Edit.ioni Minerva Medica, Corso Bramante 83-85, 10126 somolsk.ij prospckt 18, Medicinskaja Kniga, Moscow - For TURIN; Via Lamarmora 3. 20100 MILAN readers outside the USSR requiring Russian editions : Kuzneckt..i JAPAN: Ma.ruzen Co. Ltd, P.O. Box 5050, TOKYO International most 18, Meidunarodnaja Kniga, Moscow G-200 100-31 VENEZUELA: Editorial Jnteramericana de Venezuela C.A .. Apar- KOREA, REPUBLIC OF: The WHO Programme Coordinator, tado 50785, CAllACAS 105 - Librerla del fate, Apartado 60337, Central P .O . Box 540. SEOUL CARACAS 106 KUWAIT : The Kuwait Bookshops Co . Ltd, Thunayan AI-Ghanem YUGOSLAVIA : Jugoslovenska Knjiga, Teraziie 27 / II , 11000 Bldg, P .O. Box 2942, KUWAIT BELGllADE LAO PEOPLE'S DEMOCRATIC REPUBLIC: The WHO ZAIRE: Libra irie universi tai re, avenue de la Paix N • 167 , 8 .P. Progra mme Coordinator, P .O. Box: 343, VIENTIANE 1682, KINSHASA I Special terrns for d evelopi ng c ou ntries are obtainable on application to the WHO Programme Coord inators or WHO Regional Offices listed a bove or to the World Health Organ ization, Distribution and S a les S ervice, 1211 G eneva 27, Switzerland. Orders from countries where sales agents have not yet b een appointed may also be sent to the Geneva ad dress, but must be paid for in pounds sterling , US dollars, or Swiss francs . Price: Sw . fr . 20.- Prices are subject to change without notice . C /2/78