93
Round the World From our Correspondents
United States THE MULTI-HOSPITAL SYSTEM
FOR many years health-care costs have been increasing fastthan inflation and one way in which the health-care industry has been seeking to respond is by combining individual hospitals into community-wide service-shared ventures. To those in Britain, where shared services under the National Health Service have been familiar for thirty years, this move may seem unexceptional. But in the States the development is seen as a new approach that is catching on fast. The multi-hospital system was pioneered in Minneapolis in the mid-West State of Minnesota. Here it was that five years ago Fairview Community Hospitals was formed as a non profitmaking body by the consolidation of three private hospitals. Now the system comprises 18 voluntary autonomous healthcare facilities serving urban, suburban, and rural communities in the State. Fairview Community Hospitals began as Fairview Hospital Association in 1906 organised by a group of Norwegian Lutheran pastors and laymen to provide health care for the Norwegian community. In the early ’60s the board of trustees announced the development of a second hospital in Minneapolis ; and in 1973 Fairview Community Hospitals was formed with the addition of a third hospital. Today the system is a$60 million organisation with more than 3000 beds. The structure has three tiers: 5 fully owned hospitals with common assets and liabilities; 2 managed hospitals; and 11 affiliated hospitals. The man who conceived the idea of the hospital holding company, borrowing it from the world of banking, is Mr Carl Platou, president of F.C.H. Believing that the time had come for a complete reorganisation of the nation’s health-care system, he was attracted by the economies of scale which he believed a holding company would bring. He was proved right. Savings last year were estimated at$2 million, and they resulted from better management and the centralisation of specialised services, from a broader range of services and facilities, and from the stability provided by improved resources. There was a significant reduction in equipment and supply expenses, and a substantial cut in overhead expenses, achieved by centralised support services such as computerisation, inventory storage, distribution, and laundry processing. But Mr Platou recognised that the idea would work only if hospital managers and trustees carefully defined, on the one hand, the similarities in the needs of the various hospitals and, on the other hand, the unique local needs and difficulties which had to be left to divisional management. The importance of a decentralised autonomy is crucial to the system. For instance, the corporate board of F.C.H. meets only four times a year, so it will not be tempted to meddle in the operating matters of its members. Each hospital makes its own policy on ethical questions, which, for example, means that one hospital performs abortions and another does not. Mr Platou argues that the hospital holding company can improve the quality of patient care and reduce administrative costs. Every attempt is made to avoid duplication of non-emergency medical personnel, equipment, and services. There is wide coordination of laboratory services. Specimens are transported from one hospital to another: results are entered in a data-reporting system from any site and printed out at the appropriate hospital for up-to-date posting on the patient’s chart. And the new shared data-processing system, which few er
individual hospitals could afford, has led to substantial reduction in turnover time for accounts. Joint purchasing of nonperishable goods has also led to savings of up to 20%. Single-hospital institutions are now beginning to give way to large networks, as in Minnesota. The days when hospitals engaged in fierce competition to develop a complete hospital with as many as twenty medical specialties are disappearing. The Fairview system is recognised as an effective new strategy for reorganising health services. Mr Platou is now busily spreading his idea throughout the country. Over 30% of hospitals in the States are now part of a multi-unit system; and another 50% are sharing some type of services. Intense interest is manifest throughout the health-care industry in the holdingcompany concept as many hospitals search to find services and products they can profiatably supply to other institutions. The growth of such schemes is beginning to raise new questions. Potential anti-trust issues loom large. What happens, for instance, when mergers reduce the number of organisations which compete in the marketplace and some begin to use their power to put pressure on other groups? The expansion of the Fairview group beyond the borders of Minnesota is not out of the question. Mr Platou has said: "We wonder how far we really can work. If we’re working at a distance of 300 miles, why not 3000?" But he has also questioned at what stage of expansion effectiveness is lost. Much more likely, therefore, is that the group will expand within Minnesota, and one prediction is that it will consist of 30 hospitals within the next few years. Fairview has developed contacts with St Thomas’ Hospital in London. This link is enabling administrators, nurses, and finance staff to exchange information and visits. At the moment a member of St Thomas’s finance department is on secondment to Minneapolis. Mr John Owen, district administrator of St Thomas’s remarks: "Our experience of running multi-hospitals is of interest to them. We have been running multi-hospital organisations since 1948, whereas the Americans are only beginning to embark on that concept. But the Americans are far more clued-up on financial management than we are". He believes that exchange visits are particularly valuable because staff gain experience of doing their job in a different setting. "We tend in the National Health Service to have one single solution which is applied everywhere. In America pluralism is the thing they defend and we gain a lot by seeing the same thing done a different way".
DOWN WITH TAXES
DEMANDS for reduction in Government spending, to offset unbalanced budgets and extravagance, have long been heard in this land. While the rates of taxation for many seem very low to hard-pressed British taxpayers, it is easy to overlook the fact that the U.S. citizen pays what amounts to five separate taxes-at least, if he is a householder. First, he has to pay Federal income tax, then State income tax, then social security, then his local taxes, for local services and amenities, and then the local school tax. While the first three are incomebased the local and school taxes are based on ownership of property and a rate on assessed valuation. All have risen in recent years, and the social-security tax is going to bite heavily next year; but, of all of them, the local and school taxes have become most burdensome, especially as the new assessments are made. In fact some of the rises have been horrendous, and resentments have built up rapidly. In Southern California, so often the bell-wether state, assessments have gone up 120%, and this has sparked off revolt, the violence of which is proportionate to the numbers hurt. Each layer of government thinks the one above should be more economical. Thus, 23 legislatures have called for a constitutional amendment which would ban Federal deficit spending. The local authorities are all getting set to cut down spending by the State governments; and finally, at the local level,
94 taxpayers are resolved to reduce spending there too. School budgets have been repeatedly voted down; schools, especially in Ohio, have been forced to close prematurely or to limit their sessions or activities. California has voted for Proposition 13 (the Jarvis-Gann amendment) to limit sharply the amount by which property taxes can rise. Every political, Civil Service, and special-interest group has been united in furious opposition. Storm warnings have come from Governor Jerry Brown, but they have fallen on deaf ears, because so many believe that government at every level wastes money and the average taxpayer gets little for his taxes. The opponents of cuts have drawn dire pictures of the effects that will follow the passing of the Jarvis-Gann amendment. If the predictions are borne out, such an abrupt approach will be discredited. But nothing will, for the moment, stop the movement to remind politicians and all others who draw upon the public purse that there are limits to what the U.S. taxpayer will stand-and these limits have been reached. Even now it seems that the schools will be the major targets. There is widespread public feeling that the school boards and the teachers have not been doing a good job: they are accused of faddisms and of not teaching the three Rs. But other services will suffer; and there will have to be many readjustments between local and state governments. In part, however, there is an atmosphere of disillusionment with all politicians at every level and an equal distrust of Civil Servants and locally elected bodies. The average taxpayer may not be able to exert much direct effect on the Federal budget, or perhaps on the State budget, but he or she can go out and vote down the local tax proposals. This is what they did in California, by 2 to 1.
South Africa PRIMARY HEALTH CARE IN SOWETO
western-type cities, the population of Johannesexpect that its doctors should provide all primary health care. And the black population of Soweto township has been no exception. In the past, much of the primary health care for Soweto’s black population of over a million had been delivered through 45 clinics of various types, staffed by white and coloured doctors who travelled in daily. As might be expected, when the troubles came, these centres were for the most part closed, leaving a considerable void in primary health care, which could be hardly filled by the 15 or so black doctors working in the private sector. Nor could the over-worked Baragwanath Hospital just outside Soweto be expected to provide adequate primary health contacts. As South Africa, certainly in its towns, has a valuable resource of many well-qualified and effective black nurses, a programme was developed to train these nurses to provide primary health care, to take regular histories, and to undertake a general examination. This programme has been welcomed by the local Health Ministry and, more important, it has been well received by the local people. As in
burg has
most
Letters
to
the Editor
COLLAGEN DEFECT IN IDIOPATHIC SCOLIOSIS
SIR,-Research into the aetiology of idiopathic scoliosis has been beset by difficulties (often insuperable) in distinguishing between primary and secondary effects in the connective tissues of the spinal columns which have been studied. For example, we have demonstrated that changes in the total collagen content of the scoliotic disc can be related to the degree of curvature, disc mobility, and other similar mechanical indices.’2 We have, however, now done some experiments on the extractability of collagen by pepsin from scoliotic disc tissue which provide further insight into this important problem. The spines of a 15-year-old female with scoliosis and normal female control aged 16 were obtained at necropsy. Discs were dissected into zones (fig. 1). The diced, freeze-dried tissues were first extracted with 10 volumes of 0 - mol/1 sodium chloride and 20 mmol/1 sodium phosphate, pH 7-4 at 4 °C for 3x24 h to remove soluble proteoglycans. This step also removes 0-5% of the total collagen. The insoluble residues were then digested with 10 volumes of 0-1% pepsin in 0.5mol/1 acetic acid at 4 ° C for 2x24 h. The two extracts from each zone were pooled and the collagen content estimated by hydroxyproline analysis.3 The amount of collagen extracted from each zone was expressed as a percentage of the original collagen content of that zone, and the results from four normal and four scoliotic discs are shown in fig. 2. The extractability profile for the normal discs is roughly bell-shaped, symmetrically distributed about the nucleus pulposus. The amount of extractable collagen is inversely related to the total collagen content on a dryweight basis for the various zones of normal tissue. No such inverse relationship holds for the scoliotic discs. A statistically significant difference between the extractability of the transitional zones (zones 6 and 8) of the scoliotic discs and that of the controls was found. This difference seems independent of location (convex or concave side of the scoliotic disc) and thus not related to mechanical loading.
come to
Dr Lucy Wagstaff, lately appointed as the first professor of community child health in Johannesburg, has played a big part in the training of personnel and she is involved in their progressive upgrading and supervision. She relates how she walked into a clinic the other day where a nurse was talking to a mother and her child. Seeing the doctor, the mother was clearly disturbed and spoke anxiously in the local language to the nurse, who laughed and reassured her. When the mother had left, Professor Wagstaff was gratified to learn from the nurse that the mother had been worried because the doctors might be coming back to take over the primary health contacts as in the past.
1.
Taylor, T. K. F., Ghosh, P., Bushell, G. R., Sutherland, J. M. in Scoliosis: Proceedings of 5th Symposium at Brompton Hospital, London (edited by P. A. Zorab); p. 231. London, 1976. 2. Ghosh, P., Bushell, G. R., Taylor, T. K. F., Sutherland, J. M. Trans. orthop. Res. Soc. 1978, 3, 317.
Fig.
1-Manner in which normal (left) and scoliotic dissected into thirteen zones.
were
(right) discs
Round the World From our Correspondents
United States THE MULTI-HOSPITAL SYSTEM
FOR many years health-care costs have been increasing fastthan inflation and one way in which the health-care industry has been seeking to respond is by combining individual hospitals into community-wide service-shared ventures. To those in Britain, where shared services under the National Health Service have been familiar for thirty years, this move may seem unexceptional. But in the States the development is seen as a new approach that is catching on fast. The multi-hospital system was pioneered in Minneapolis in the mid-West State of Minnesota. Here it was that five years ago Fairview Community Hospitals was formed as a non profitmaking body by the consolidation of three private hospitals. Now the system comprises 18 voluntary autonomous healthcare facilities serving urban, suburban, and rural communities in the State. Fairview Community Hospitals began as Fairview Hospital Association in 1906 organised by a group of Norwegian Lutheran pastors and laymen to provide health care for the Norwegian community. In the early ’60s the board of trustees announced the development of a second hospital in Minneapolis ; and in 1973 Fairview Community Hospitals was formed with the addition of a third hospital. Today the system is a$60 million organisation with more than 3000 beds. The structure has three tiers: 5 fully owned hospitals with common assets and liabilities; 2 managed hospitals; and 11 affiliated hospitals. The man who conceived the idea of the hospital holding company, borrowing it from the world of banking, is Mr Carl Platou, president of F.C.H. Believing that the time had come for a complete reorganisation of the nation’s health-care system, he was attracted by the economies of scale which he believed a holding company would bring. He was proved right. Savings last year were estimated at$2 million, and they resulted from better management and the centralisation of specialised services, from a broader range of services and facilities, and from the stability provided by improved resources. There was a significant reduction in equipment and supply expenses, and a substantial cut in overhead expenses, achieved by centralised support services such as computerisation, inventory storage, distribution, and laundry processing. But Mr Platou recognised that the idea would work only if hospital managers and trustees carefully defined, on the one hand, the similarities in the needs of the various hospitals and, on the other hand, the unique local needs and difficulties which had to be left to divisional management. The importance of a decentralised autonomy is crucial to the system. For instance, the corporate board of F.C.H. meets only four times a year, so it will not be tempted to meddle in the operating matters of its members. Each hospital makes its own policy on ethical questions, which, for example, means that one hospital performs abortions and another does not. Mr Platou argues that the hospital holding company can improve the quality of patient care and reduce administrative costs. Every attempt is made to avoid duplication of non-emergency medical personnel, equipment, and services. There is wide coordination of laboratory services. Specimens are transported from one hospital to another: results are entered in a data-reporting system from any site and printed out at the appropriate hospital for up-to-date posting on the patient’s chart. And the new shared data-processing system, which few er
individual hospitals could afford, has led to substantial reduction in turnover time for accounts. Joint purchasing of nonperishable goods has also led to savings of up to 20%. Single-hospital institutions are now beginning to give way to large networks, as in Minnesota. The days when hospitals engaged in fierce competition to develop a complete hospital with as many as twenty medical specialties are disappearing. The Fairview system is recognised as an effective new strategy for reorganising health services. Mr Platou is now busily spreading his idea throughout the country. Over 30% of hospitals in the States are now part of a multi-unit system; and another 50% are sharing some type of services. Intense interest is manifest throughout the health-care industry in the holdingcompany concept as many hospitals search to find services and products they can profiatably supply to other institutions. The growth of such schemes is beginning to raise new questions. Potential anti-trust issues loom large. What happens, for instance, when mergers reduce the number of organisations which compete in the marketplace and some begin to use their power to put pressure on other groups? The expansion of the Fairview group beyond the borders of Minnesota is not out of the question. Mr Platou has said: "We wonder how far we really can work. If we’re working at a distance of 300 miles, why not 3000?" But he has also questioned at what stage of expansion effectiveness is lost. Much more likely, therefore, is that the group will expand within Minnesota, and one prediction is that it will consist of 30 hospitals within the next few years. Fairview has developed contacts with St Thomas’ Hospital in London. This link is enabling administrators, nurses, and finance staff to exchange information and visits. At the moment a member of St Thomas’s finance department is on secondment to Minneapolis. Mr John Owen, district administrator of St Thomas’s remarks: "Our experience of running multi-hospitals is of interest to them. We have been running multi-hospital organisations since 1948, whereas the Americans are only beginning to embark on that concept. But the Americans are far more clued-up on financial management than we are". He believes that exchange visits are particularly valuable because staff gain experience of doing their job in a different setting. "We tend in the National Health Service to have one single solution which is applied everywhere. In America pluralism is the thing they defend and we gain a lot by seeing the same thing done a different way".
DOWN WITH TAXES
DEMANDS for reduction in Government spending, to offset unbalanced budgets and extravagance, have long been heard in this land. While the rates of taxation for many seem very low to hard-pressed British taxpayers, it is easy to overlook the fact that the U.S. citizen pays what amounts to five separate taxes-at least, if he is a householder. First, he has to pay Federal income tax, then State income tax, then social security, then his local taxes, for local services and amenities, and then the local school tax. While the first three are incomebased the local and school taxes are based on ownership of property and a rate on assessed valuation. All have risen in recent years, and the social-security tax is going to bite heavily next year; but, of all of them, the local and school taxes have become most burdensome, especially as the new assessments are made. In fact some of the rises have been horrendous, and resentments have built up rapidly. In Southern California, so often the bell-wether state, assessments have gone up 120%, and this has sparked off revolt, the violence of which is proportionate to the numbers hurt. Each layer of government thinks the one above should be more economical. Thus, 23 legislatures have called for a constitutional amendment which would ban Federal deficit spending. The local authorities are all getting set to cut down spending by the State governments; and finally, at the local level,
94 taxpayers are resolved to reduce spending there too. School budgets have been repeatedly voted down; schools, especially in Ohio, have been forced to close prematurely or to limit their sessions or activities. California has voted for Proposition 13 (the Jarvis-Gann amendment) to limit sharply the amount by which property taxes can rise. Every political, Civil Service, and special-interest group has been united in furious opposition. Storm warnings have come from Governor Jerry Brown, but they have fallen on deaf ears, because so many believe that government at every level wastes money and the average taxpayer gets little for his taxes. The opponents of cuts have drawn dire pictures of the effects that will follow the passing of the Jarvis-Gann amendment. If the predictions are borne out, such an abrupt approach will be discredited. But nothing will, for the moment, stop the movement to remind politicians and all others who draw upon the public purse that there are limits to what the U.S. taxpayer will stand-and these limits have been reached. Even now it seems that the schools will be the major targets. There is widespread public feeling that the school boards and the teachers have not been doing a good job: they are accused of faddisms and of not teaching the three Rs. But other services will suffer; and there will have to be many readjustments between local and state governments. In part, however, there is an atmosphere of disillusionment with all politicians at every level and an equal distrust of Civil Servants and locally elected bodies. The average taxpayer may not be able to exert much direct effect on the Federal budget, or perhaps on the State budget, but he or she can go out and vote down the local tax proposals. This is what they did in California, by 2 to 1.
South Africa PRIMARY HEALTH CARE IN SOWETO
western-type cities, the population of Johannesexpect that its doctors should provide all primary health care. And the black population of Soweto township has been no exception. In the past, much of the primary health care for Soweto’s black population of over a million had been delivered through 45 clinics of various types, staffed by white and coloured doctors who travelled in daily. As might be expected, when the troubles came, these centres were for the most part closed, leaving a considerable void in primary health care, which could be hardly filled by the 15 or so black doctors working in the private sector. Nor could the over-worked Baragwanath Hospital just outside Soweto be expected to provide adequate primary health contacts. As South Africa, certainly in its towns, has a valuable resource of many well-qualified and effective black nurses, a programme was developed to train these nurses to provide primary health care, to take regular histories, and to undertake a general examination. This programme has been welcomed by the local Health Ministry and, more important, it has been well received by the local people. As in
burg has
most
Letters
to
the Editor
COLLAGEN DEFECT IN IDIOPATHIC SCOLIOSIS
SIR,-Research into the aetiology of idiopathic scoliosis has been beset by difficulties (often insuperable) in distinguishing between primary and secondary effects in the connective tissues of the spinal columns which have been studied. For example, we have demonstrated that changes in the total collagen content of the scoliotic disc can be related to the degree of curvature, disc mobility, and other similar mechanical indices.’2 We have, however, now done some experiments on the extractability of collagen by pepsin from scoliotic disc tissue which provide further insight into this important problem. The spines of a 15-year-old female with scoliosis and normal female control aged 16 were obtained at necropsy. Discs were dissected into zones (fig. 1). The diced, freeze-dried tissues were first extracted with 10 volumes of 0 - mol/1 sodium chloride and 20 mmol/1 sodium phosphate, pH 7-4 at 4 °C for 3x24 h to remove soluble proteoglycans. This step also removes 0-5% of the total collagen. The insoluble residues were then digested with 10 volumes of 0-1% pepsin in 0.5mol/1 acetic acid at 4 ° C for 2x24 h. The two extracts from each zone were pooled and the collagen content estimated by hydroxyproline analysis.3 The amount of collagen extracted from each zone was expressed as a percentage of the original collagen content of that zone, and the results from four normal and four scoliotic discs are shown in fig. 2. The extractability profile for the normal discs is roughly bell-shaped, symmetrically distributed about the nucleus pulposus. The amount of extractable collagen is inversely related to the total collagen content on a dryweight basis for the various zones of normal tissue. No such inverse relationship holds for the scoliotic discs. A statistically significant difference between the extractability of the transitional zones (zones 6 and 8) of the scoliotic discs and that of the controls was found. This difference seems independent of location (convex or concave side of the scoliotic disc) and thus not related to mechanical loading.
come to
Dr Lucy Wagstaff, lately appointed as the first professor of community child health in Johannesburg, has played a big part in the training of personnel and she is involved in their progressive upgrading and supervision. She relates how she walked into a clinic the other day where a nurse was talking to a mother and her child. Seeing the doctor, the mother was clearly disturbed and spoke anxiously in the local language to the nurse, who laughed and reassured her. When the mother had left, Professor Wagstaff was gratified to learn from the nurse that the mother had been worried because the doctors might be coming back to take over the primary health contacts as in the past.
1.
Taylor, T. K. F., Ghosh, P., Bushell, G. R., Sutherland, J. M. in Scoliosis: Proceedings of 5th Symposium at Brompton Hospital, London (edited by P. A. Zorab); p. 231. London, 1976. 2. Ghosh, P., Bushell, G. R., Taylor, T. K. F., Sutherland, J. M. Trans. orthop. Res. Soc. 1978, 3, 317.
Fig.
1-Manner in which normal (left) and scoliotic dissected into thirteen zones.
were
(right) discs
