2007 John F. Roatch

GLOBAL
LECTURE
S E R I E S
on Social Policy and Practice

2007

John F Roatch Global Lecture Series on Social Policy and Practice

Is There Still A Place For Traditional Values
In Family Medicine?
Confronting Managed Care
Presented by
John Wynn-Jones, M.D.
March 30, 2007

With gratitude

The present
to Mary Roatch

The John and Mary Roatch Endowment was
created by gifts made to the university by John and
Mary Roatch. The endowment provides support
for the Global Lecture Series, which are organized
through the office of the John F. Roatch
Distinguished Professor at University College.
John Roatch was born in Ellsworth, Wisconsin, on
May 3, 1921 and died in Phoenix, Arizona, on July 2, 1997. Mary was born to
missionary parents in Darjeeling, India, and resides in Phoenix. The Roatches have
four children, Virginia, Thomas, David, and Joseph. Both Mary and John met and
graduated from Hamline University in St. Paul, Minnesota.
John received a master of social work from Washington University in St. Louis,
Missouri. He practiced social work and was director of the social work department
at the Clinical Center of the National Institute of Health in Bethesda Maryland,
from 1965 to 1972. Mary was a teacher, a cottage-parent, and a tutor, but her real
love was being a librarian and a consultant on libraries for persons with special
needs. She worked at the Phoenix Public Library where she organized the first
Special Needs Center in 1983. We continue to be indebted to John and Mary for
their vision and to all the family for their continued support of the Lecture Series.
The John F. Roatch Global Lecture Series has always been at the forefront in
covering timely topics. In January 2007, the Arizona Republic published an editorial
by the president of the Arizona Medical Society in which he addressed the
vanishing family doctor. When this editorial appeared, we had already invited
Dr. John Wynn-Jones who had accepted our invitation to speak on a similar topic.
Our foresight brought forth great results, for the 2007 lecture was a resounding
success. Dr. Wynn-Jones, as keynote speaker and Drs. Weisbuch and Bradshaw, as
respondents, provided an enlightening discourse on what is one of the most
important keys to good health—a well-prepared and caring primary physician.
We are endebted to these generous professionals for their time, their wisdom, most
of all, for their willingness to share their gifts with our audience.
Emilia E. Martinez-Brawley
John F. Roatch Distinguished Professor and
Professor of Social Work
2007

Celebrating
John F. Roatch’s
Legacy

The memory

“When I first practiced
family practice, we
provided a fully
comprehensive level of
care to our patients. This
included obstetric care
and in-patient care for
our patients with serious
illnesses in our small
community hospitals. We
also visited many of our
patients at home. Sadly, our
visiting rates have reduced
by at least 80 percent
and there is a danger that
we may become
hermetically sealed within
our own surgery or office
environment. It is
surprising what you
can learn about somebody
by visiting their
home environment.”

5

“T

oday, I aim to discuss the importance of human contact and

communication in the delivery of effective patient-centred health care.

How can we as physicians, working in health systems that are
becoming increasingly process driven and disease-focused, maintain
human dignity and a patient sensitive approach? I will argue that
traditional values in family practice still offer us the opportunity to
meet and focus on the modern needs of individuals and communities
rather than on the needs of the health care industry.”

John Wynn-Jones, MD
University of Wales, College of Medicine

DR. JOHN WYNN-JONES is a practicing general practitioner in
Montgomery, Powys, Wales. John is well known nationally and
internationally for his pioneering work in e-health and for his
special interest in education, having held a post with the University of
Wales College of Medicine for many years. John is also Life President
of the Institute of Rural Health, President of Euripa (European Rural
and Isolated Practitioners Association), a member Institute of Learning and Teaching (ILTM), and a Fellow
of the Royal College of General Practitioners. He has been a speaker on a variety of health topics and
family practice issues in Spain, Germany, Norway, and the U.S.
Dr. Wynn-Jones’ practice in Wales is carried out in a team with four full-time and one part-time doctor
serving 7,300 patients. The team includes a nurse practitioner, a practice nurse, a triage nurse, a
chiropodist, three district nurses, two health visitors, seven receptionists, and a practice manager. Recent
regulatory changes for general practice in the United Kingdom established a coordinated out-of-hours
service in response to the need to permit general practitioners to balance work and family. The new
medical contract also provides general practitioners sophisticated IT support, which is owned and
maintained by the primary care organization.
In the European Union, which recently increased to close to 30 independent states, there are as many
different models of health care delivery, language and culture. There are large inequalities in health and
poverty. Dr. Wynn-Jones has been a student of accessibility and quality issues, but, most of all, has been
concerned with maintaining the commitment to caring for people, which initially inspired so many
family practitioners to go into medicine.
As an interesting aside, he is the medical adviser to the “Archers,” a radio program in the U.K.

Scenes from the Lecture

7

Is There Still

“I would like to draw your attention to one of the

A Place For
Traditional Values
In Family Medicine?

most seminal books on family practice/general
practice, A Fortunate Man, by John Burger.
It is about a man called Sassall who is a country

Confronting

doctor. Burger says he is a fortunate man because

Managed Care

his work occupies him and fulfills him. His work
and his life are not separate, but are closely
intertwined.”

March 30, 2007

INTRODUCTION

I

would like to give special thanks to my sponsor, Mrs. Mary Roatch, and host,
Emilia Martinez-Brawley, for inviting me to join you today.
You may ask yourselves how a rural family practitioner from Wales came to be
giving such a prestigious lecture in Phoenix, Arizona. I had the good fortune to
meet my host, Emilia, at a rural and remote health conference in Norway. We
found ourselves giving keynotes back-to-back and hit it off from the start. Twelve
months later, I was delighted when my long-lost speaking partner phoned me
up and invited me to join you today.
As we start the 21st century, I do not know of a nation that can afford to fund
comprehensive health care for its people. Countries throughout the developed
world are finding it increasingly difficult to meet the rising costs of health and
social care in the climate of health cost inflation, greater inequalities, and an
aging population. Health systems evolve to meet national demography, political
aspirations, and the national psyche. One size does not fit all and one country’s
solution is not transferable to another, but we can learn from each other and share
views, ideas, and initiatives in order to improve the health of our own populations.
I am not an academic. My main role is as a rural practitioner working in family
medicine (or general practice as we call it in the United Kingdom), in rural Wales.
I have seen major changes in medicine, society, and government during the 27
years that I have served my community and the 20 years I have been a tutor and
lecturer. I have witnessed major advances in the technology of health care,
changes in the way that society views physicians and the expectations that are
placed on us. These changes have had an impact on my working life. As the rate
of change accelerates, we find it harder to keep our heads above water, thus
increasing our stress and reducing our capacity. I am not a health economist or a
strategic planner. I will, however, give a “bottom up” view, emphasizing the
importance and value of primary care, family practice, and the “human effect“ in
the development of cost effective, equitable, and accessible health care.
Today, I aim to discuss the importance of human contact and communication in
the delivery of effective patient-centred health care. How can we, as physicians
working in health systems that are becoming increasingly process driven and
disease-focused, maintain human dignity and a patient sensitive approach? I will
argue that traditional values in family practice still offer us the opportunity to
meet and focus on the modern needs of individuals and communities rather than

8

on the needs of the health care industry. I will start by
giving you a personal perspective of my work, my
experiences, and my family practice. I need to explain why
I chose this title. What were my driving passions in taking
on this arduous task? I will then spend some time arguing
the need for effective primary care and, especially,
accessible and responsive family practice. The presentation
will describe how today’s family physicians have evolved
into the “new generalists” who have become the lynchpin
of modern and effective health systems. We will discuss
the birth and growth of managed care and what impacts
that might have on the values of traditional family practice.
The presentation will explain more about the “human
effect” and the therapeutic benefits of the consultation,
effective communication, and an enduring relationship
between practitioner and patient.
I will try to put these issues in the context of both our
health systems in the United Kingdom and the United
States. We will explore the differences and identify how
we can learn from each other. I want to emphasize that I
do not intend to criticize the American system in
comparison with the United Kingdom. Both countries have
similar life expectancies and health outcomes, which are
often worse than some of the other developed nations.
The changes that have taken place in the U.K. with a new
family medicine contract have the potential for major
impact on the health of our nation and I will illustrate
these changes with data from my own practice. I wonder
whether the concept of a single-payer, accessible,
free-at-the-point-of-contact primary care service may have
a certain resonance in states such as Arizona, especially in
light of recent articles published in the Arizona Republic in
January this year, which have many equivalents in the
British press.
I intend to conclude by offering some suggestions on
how we can make compromises by incorporating what is
best in managed care and traditional care and use it to
shape our new health services in the 21st century.

Finally, I have a specific interest in how we train the next
generation of health care practitioners. We must use the
best practice to build an image of what our future doctors
should look like and accordingly shape the undergraduate
and postgraduate curricula in order to produce a
workforce “fit for purpose”.

A PERSONAL PERSPECTIVE
I would like to draw your attention to one of the most seminal
books on family practice/general practice, A Fortunate Man
(1967), by John Burger. It is about a man called Sassall who is a
country doctor. Burger says he is a fortunate man because his
work occupies him and fulfills him. His work and his life are
not separate, but are closely intertwined.
Sassall is my hero and at the same time represents an age
gone by. Burger describes the transition by which a
scientifically orientated, disease-focused doctor begins to
change in the new environment in which he works. He
describes how he learns the language of his patients. He
learns the importance of that unique enduring relationship
with his patient, the spontaneity of that moment when all
may be revealed. He feels inadequate when he doesn’t
know what to do and how to behave. He struggles with
the expectations that doctors and patients place on each
other. His role as a family physician is that of a universal man.
He describes the birth of the “new physician” or the “new
generalist” that began to appear in 1960s. More than anything else, however, he tells us that Sassall’s most important
role is in the management of “anguish” in his patients.
When I first practiced family practice, we provided a fully
comprehensive level of care to our patients. This included
obstetric care and in-patient care for our patients with
serious illnesses in our small community hospitals. We also
visited many of our patients at home. Sadly, our visiting rates
have reduced by at least 80 percent and there is a danger
that we may become hermetically sealed within our own
surgery or office environment. It is surprising what you can
learn about somebody by visiting their home environment.

WHY I CHOSE THIS SUBJECT
I chose this subject for a number of reasons. Some of
this emanates from my own personal frustrations and
experiences in practice. I have to ask myself whether it is
just one of those age things! Do all doctors feel like this
when they get past 55 years old? I can remember my
ex-partners feeling similar concerns about the direction of
their profession in the past. I have, however, had the
good fortune to travel extensively and experience good
family practice around the world. I believe that crucial
elements of traditional practice are being lost in the U.K.,
and I grasped the opportunity to confront the march of
“managed care” and critically argue the case for
traditional values to remain. It is clear, however, that a
more managed care program can provide the opportunity
to handle the 21st century challenge of an aging
population with chronic disease in need of high levels of
care. I felt that by comparing the strengths and
weaknesses of both health systems I could identify what
we both do well and what we can learn from each other.

But, I have seen major changes during my 27 years in
practice. The most significant have been due the advances
in medical technology. We can now do more for our
patients, we have more treatment options, we have more
information at our finger tips, our patients expect more
from us, and they live longer. No longer does a patient tell
us “don’t worry, doctor, but you did all that you could”.
Expectations are greater and are often unachievable. Our
patients are also more informed, and our relationships
have changed. Health care is now based on partnerships
rather than the traditional parent-child relationships.
Workload and stress have grown exponentially. The aging
of our practice population has made the management of
chronic diseases, and especially the problems associated
with co-morbidity of multiple complex chronic diseases,
our biggest challenge to date. One-fifth of the U.K.
population is over 60 years old. Within 30 years, the
numbers over 65 will rise from 18 percent to 22 percent
while those under 20 will drop from 25 percent to 22

9

percent. The elderly already consume a large proportion of
the NHS budget with 40 percent spent on the over
65-year-olds (while over 50 percent of the social services
budget is spent on this age group). In order to cope,
much of the chronic disease management is now
undertaken by nurses and nurse practitioners working to
protocols. The nature of family practice has changed, with
care being provided through complex horizontally
integrated multidisciplinary primary health care teams.
The quality/safety/governance agenda has also impacted
our work. Patients, understandably, expect high levels of
quality and governance. Many of the procedures and
treatments that we regularly provided are now deemed to
be specialist only. We are told that we no longer have the
competencies to practice procedures that were once the
domain of the family practitioner. We are increasingly
becoming de-skilled and this, in turn, increases work for
secondary care and causes a reduction in job satisfaction.
The dynamics of our practices have also changed. Practices
have become bigger and more complex. Time involved in
management, paperwork, and administration impinges on
clinical time and patient contact. In Britain, family
physicians were given the option of relinquishing 24-hour
responsibility for their patients three years ago. This has
clearly improved our work-life balance, however, as a
result, I feel GPs have lost status and have lost credulity.
We interact less and less with our community and our role
as community leaders is disappearing all the time. We are
becoming less relevant as agents of change.
Attitudes in society are also changing and our community
sees us in a very different light. Society is less forgiving and
more demanding. As we share less and less of our
patients’ anguish, we become just another professional
group who are well paid, protectionist, and look after their
own self interests.

for a local emergency care company. We no longer provide
maternity services or look after patients in hospital.
We have established a patients group, which meets on a
regular basis and advises us on our patient services.

THE STRENGTHS OF PRIMARY CARE
Barbara Starfied and other authors have conducted
extensive research into the impact of effective primary
care. In a Health Policy document, Starfield and Shi (2002)
state health care costs are directly related to the strength
of primary care. Countries with weak primary care
infrastructures have poorer performance on major aspects
of health, although countries that are intermediate in the
strength of their primary care generally have levels of
health at least as good as those with high levels of primary
care. This is not the case in early life when the impact of
strong primary care is greatest. Equitable distribution of
resources, publicly accountable universal health and
financial coverage, and comprehensive and family-orientated
social services distinguish countries with overall good
health from those with poor health at all ages. Neither
income inequalities nor smoking status accurately identify
those countries with consistently high or consistently poor
performance on health indicators. A certain level of health
care expenditures may be required to achieve overall good
health levels, even in the presence of strong primary health
care infrastructures. Very low costs may interfere with the
achievement of good health, particularly at older ages,
although higher levels of costs may signal excesses and
potentially health compromising care. The policy-relevant
characteristics aforementioned appear to be related to
better population health levels. Studies showed that mortality
levels in countries with high quality primary care consistently
outperformed those with low-quality primary care. These
comparisons are also applicable across American states with
stroke mortality and post neo-natal mortality.

Care has become increasingly more disease-focused
rather than patient-centred. We are in danger of providing
a mechanistic type of care based on things that we can
measure rather than the suffering that we can alleviate.

Starfield (1985 & 2002) has consistently championed the
importance of strong and comprehensive primary care as a
basis for a nation’s health, and her evidence has indicated
that this relationship remains true irrespective of a nation’s
GDP or the proportion of its GDP spent on health.

MY MEDICAL PRACTICE IN MONTGOMERY, WALES

FAMILY PRACTICE: THE HISTORICAL PERSPECTIVE

My practice in Montgomery, Wales is not just a team but a
complex organisation. We have five doctors and the team
cares for 7,300 patients. We work out of two surgeries.
We have one nurse practitioner and four practice nurses,
and their main role is the management of minor illnesses
and chronic disease in the practice. We have a counsellor,
a psychiatric nurse. We provide telephone nurse triage
throughout the day. We have a chiropodist, two health
care assistants, four district visiting nurses, two health
visitors who work as public health children’s nurses. We
have access to specialist nurses who join us for our weekly
multi-disciplinary meeting, such as a palliative care nurse,
urology incontinence nurse, etc. We have a practice
manager who manages this organisation. She is helped by
twelve receptionists and dispensers. Five doctors still
provide “out of hours” services on a shift basis, working

Family practice is placed at the core of strong primary care
and remains one of the most important elements. The
family physician provides the interface between the patient
and the health service by providing care when necessary,
referring horizontally to other members of the team when
appropriate, and acting as the gatekeeper to secondary
care when needed. The majority of care will be provided
through primary care without any need to refer on.
Family practice is in a period of change, but change in
medicine is not new. Medicine as we know it developed
as a profession in the 19th century. Before then, there
were a small number of elite physicians and a whole array
of unregulated healers, surgeons, apothecaries, midwives,
etc. providing care to the majority of the population.

10

The 19th century was the age of regulation. Both the
government and the profession gradually regulated and
controlled medicine in order to safeguard the public.
Examples were the Apothecary’s Act, 1815; the 1st Bill for
The Regulation of the Medical Profession,1840; the
Charter for the Formation of the Royal College of Surgeons,
1843; and the National Association of General Practitioners,
1845. It was out of this period of regulation and evolution
that the first general practitioner developed. A general
practitioner was considered to be a physician who
was trained in and able to provide surgical, medical, and
midwifery practice.
The 20th century saw the birth of specialisation in
medicine. The great majority of physicians at the end of
the 19th century were generalists. For the first time,
scientific advance was linked to the practice of medicine.
Johns Hopkins University, in particular, was formed by
specialists to place medical education on a firm scientific
foundation. As a result, medical education became
increasingly laboratory orientated.
Through the early part of the 20th century, the family
practitioner was overshadowed by the hospital orientated
specialist. By the1960s, there were three recognized levels
of care: primary care, provided by generalists practicing
personal and comprehensive care; secondary care,
provided by specialists; and tertiary care, provided at
highly specialized centres.
General Practice/Family Medicine has constantly evolved
as a discipline and responded to the changing health
environment and economy. By the 1970s, we began to see
the need for a “new generalist” working in primary care.
This new type of family physician developed as a response
to the expansion of primary care. This new physician
provided generalist patient-centred care. Around them
grew a need for an academic infrastructure, and this led to
the establishment of colleges, associations, and university
departments. This new discipline led to the setting up of
specialist training programmes and the establishment of
Family Medicine/General Practice as a specialist discipline.
The growing research base began to look at how doctors
performed and behaved, how patients sought help,
and the importance of patient-centred care. This led to
the incorporation of behavioural and social sciences into
medical education and research. Primary care/family
practice research has grown considerably and now
accounts for a significant proportion of the biomedical
academic output. Modern research has needed to embrace
qualitative as well as quantitative research methodologies.
This era also saw the changing face of hospitals, with the
growth of care outside the hospital environment and
expanded community services. Economists realised that
community care was cheaper, and strategic planning
aimed to reduce hospital admissions when possible.
Hospital stays became short and time spent in hospital was
highly intensive. It is during this time that the concept of
managed care arose in an attempt to rationalise and
contain the costs and the use of resources.

The evolution of family medicine/general practice has had
an impact on medical education. Students were traditionally
trained in hospital because hospitals were places that
patients went to. The realisation that the majority of sick
people are treated in primary care and the shift of care into
the community has meant that undergraduate training
needed to be re-orientated to family and community
practice. Students not only learn about family practice
from family practitioners, but the change in hospital
practice means they now also need to learn their basic
skills and medical knowledge in the community. New and
innovative medical schools in countries such as Australia
see medical students spending between six and 12 months
in family and community practice.

FAMILY PRACTICE DEFINITION AND ROLES
Ian McWinney, in his Textbook of Family Medicine (1981),
stresses the importance of being different and having a
different role to other disciplines. He described Family
Practice as the only discipline which defines itself in terms
of relationships, thinks in terms of individuals rather than
diseases, and transcends the gulf between mind and body.
He goes on to list the nine principles of family practice:
1)
2)
3)
4)
5)
6)
7)
8)
9)

Family physicians are committed to the person
rather than a particular body of knowledge, group of
diseases, or special techniques.
The family physician seeks to understand the context
of the illness.
The family physician sees every contact with his
patient as an opportunity for prevention or health
education.
The family physician views his or her practice as a
population at risk.
The family physician sees himself or herself as part
of a countrywide network of supportive and health
care agencies.
Ideally, family physicians should share the same
habitus as their patients.
The family physician sees patients in their own homes.
The family physician attaches importance to subjective
aspects of medicine.
The family physician is a manager of resources.

The family physician is also the key to the horizontal and
vertical integration of health care delivery. The concept of
an enduring relationship which spans a period of time is a
crucial element in the management of individuals and
communities allowing the physician the opportunity to use
experience and personal knowledge to solve problems as
they arise. Self reflection, critical thinking, and lifelong
learning ensures that the physician is always striving to
improve care and incorporate advances in science and
medicine into their individual practice. McWhinney also
recognises that there are potential conflicts between a
family physician’s role and his/her responsibilities. These
challenges are often associated with achieving the balance
between science, experience, and the subjective; learning
who defines the problem, the patient or the doctor;
resolving potential conflicts between the needs of an
individual and that of the group; deciding how much time

11

should be spent in management and away from patient care; investigating how
the quality agenda impacts traditional care and values; discovering conflicts that
might occur between the needs of government and the needs of the patient; and
finally, ensuring that the family physician achieves a work-life balance, a balance
that will benefit the physicians, their families and their patients.

CONTINUITY OF CARE
Modern health care often means that patients are seen by many practitioners
and professionals. It is conceivable that care may, as a result, become
fragmented. Continuity of care must, therefore, remain a prerequisite of modern
family practice. Attlinger & Freeman (British Medical Journal, 1981) stated:
“Continuity of care improves both patient satisfaction within a general practice
service, but also, more importantly, improves compliance with medical advice. It
seems that patients who get to know their GP (and by implication are able to
develop a good relationship with the doctor) are more likely to take pills as advised.”

“We must improve the
patient experience by
adopting patient-centred
rather than disease-focused
approaches. Doctors must
forge therapeutic
relationships and contracts
with their patients and
families. These relationships
must maintain patient
autonomy, foster self care,
and avoid dependence on
the physician.”

But, authors suggest, continuity of care must be also looked at from the patient’s
point of view. There is some evidence that personal continuity, as opposed to
organisational continuity, brings forth greater patient satisfaction with care and
more efficient use of resources. It has also been proposed that a service needs
to provide: continuity of information—excellent information transfer following
the patient; cross-boundary and team continuity—effective communication
between professionals and services and with patients; flexible continuity—adjust
to the needs of the individual over time; longitudinal continuity—patient follow
up across time; and relational continuity—a named individual professional with
whom the patient can establish and maintain a therapeutic relationship.
McWhinney (1981) summarizes that continuity of care is built on an enduring
relationship between patient and physician, based on the four principles of
responsibility, trust, relationships, and accumulated knowledge.

ARE THERE WEAKNESSES
IN TRADITIONAL FAMILY PRACTICE?
Do we need a generalist in this modern world? Clearly, the patient needs a
trusted and informed physician who can support, steer, and protect them
through the growing labyrinth of modern health care. The trusted family
physician needs to protect against over-medicalisation, acting as the patient’s
advocate, and translator. Sceptics may argue whether the family physician can
keep up with growing body of scientific knowledge. The new generalist is a
specialist in generalism. Their knowledge is extensive and it allows them to
transcend the various barriers that often arise between individual medical
specialties and sub-specialities. I understand that the term “gatekeeper” is
perceived in the USA as a barrier, which may restrict freedoms and a patient’s
options. Gatekeepers can also welcome and protect individuals, help them
choose the most appropriate option, and guide them along on their journey.
It may be argued that the family practitioner can act as a barrier between the
smooth integration of primary and secondary care. Family physicians need to
communicate effectively with their specialist colleagues. This communication can,
on one hand, ensure that patient information flows easily across the border
between primary and secondary care and, on the other, that they work together
to create pathways of care in order to guide the patient on their journey
effectively, efficiently, and safely.

THE UNITED KINGDOM NATIONAL HEALTH SERVICE
The National Health Service (NHS) in the United Kingdom was established in
1948. It aimed to provide a service “from the cradle to the grave”. The wartime
government, in 1942, commissioned William Beveridge to write a report which
would lay the foundations for a “modern welfare state” and provide a “society

12

fit for the soldiers to come home to at the end of
hostilities”. Lord Beveridge said that the object
of government is not the glory of rulers or of races but
the happiness of the common man. There was a time
when the NHS was the envy of the world. I cannot say that
it is the case now but we can still maintain some pride in
a system that provides comprehensive care irrespective of
wealth and free at the point of entry with a single payer. In
1990, a similar time to when managed care organisations
in the United States were expanding, Margaret Thatcher
introduced the market economy into health care in the
United Kingdom in an attempt to make it more efficient,
more effective, and produce value for money.

GENERAL PRACTICE IN THE UNITED KINGDOM
You will need to know more about the nature of general
practice in the United Kingdom. The NHS is a centrally
co-ordinated service. It has a single payer in the U.K.
government and is free at the point of delivery. GPs act as
gatekeepers, co-ordinating referral to secondary care and
at the same time identifying the appropriate care for their
patients. GPs work as independent contractors; they are
not government employees, although they have the
benefits of the NHS pension scheme. Their pay structure is
complex and consists of a mixture of capitation, item for
service, and target base payments. Premises and staff are
subsidised. General practitioners work in teams with an
array of other primary health care professionals.
The Health Service has gone through a considerable
amount of change over the last two decades and this has
been a de-stabilizing factor on general practice. The new
GP or General Medical Services Contract has radically
altered the service. Roland, describing the new contract in
the New England Journal of Medicine, (2005) said, “The
1990s were the years of evidence-based medicine, when
health professionals gradually came to accept that there
were better and worse ways of doing things and there
were justifiable limits to individual freedom in the clinical
setting”. The 1990’s was also a decade when researchers
in health care on both sides of the Atlantic demonstrated
that there were widespread variations in the practice of
medicine and that many patients were receiving care that
fell short of what could be provided. The combined effect
of these developments was that it became increasingly
possible both to define high-quality care and to provide
methods that could be used to measure some aspects of
the quality of care”. The change in the culture of the
profession that occurred during this decade was
enormous, and it stemmed in large part from research in
the health services that was carried out in the United
States and the United Kingdom. A recent editorial in the
BMJ, describing the new GMS contract, commented that
the proposed new contract between the NHS and the
general practitioners aims to improve the quality of
primary care in the boldest, large scale proposal ever
attempted anywhere in the world.

THE NEW GMS CONTRACT
The new GP or General Medical Services Contract
introduced in 2004 has radically altered the service. The
new contract originated as a result of a survey of general
practitioners carried out in 2001. Over half the GP
respondents felt so overworked and stressed that they had
considered leaving the health service, and it became clear
that doctors wished to achieve a better work-life balance.
A new formula for funding was developed. It broke down
general medical services into core services, additional
services (such as child surveillance, immunisations, cervical
cytology), and enhanced services that could be
commissioned on a local or national basis (anticoagulation,
minor injuries, minor surgery etc.). The revolutionary
development was what became known as the “Quality
and Outcomes Framework”. This identified a number of
chronic disease areas (cardiac disease, hypertension,
diabetes, asthma, COPD, mental health etc.) and outlined
a set of targets with which to measure their management.
Each chronic disease area was allocated points. GPs were
remunerated with “new money” for each point achieved.
Points were also allocated for management targets such as
the quality of records, information for patients, practice
services, the patient experience, etc. The new contract also
gave general practitioners the opportunity to opt out of
24-hour care for the first time. In addition, the government
took over the responsibility of providing sophisticated
information technology systems in general practice.
Some GPs have mixed feelings about this contract.
Incomes have risen and workloads have expanded, but
there is no doubt that it has succeeded in improving the
management of chronic diseases. It is too early to look at
the health outcomes, but anecdotal evidence appears to
suggest a reduction in certain presenting conditions.
Incidentally, the abandonment of 24-hour care has
increased hospital admissions and placed undue stress on
the hospital services. The NHS drugs budget has also
soared with the aggressive use of expensive drugs such as
statins to reduce cholesterol.
In an attempt to meet the targets, practices have
increased the number of practice nurses. The contract has
led to an expansion in primary care teams and more
traditional medical tasks being undertaken by nurses.
The data presented (slides) from my practice shows a
range of patient health parameters which have
consistently risen over the last three years as a result of
our intensive and coordinated programme of chronic
disease management. Our practice has achieved maximum
points every year. No other practice in our Health Board
has managed to achieve these results.
Sceptics will suggest that this is a form of managed care
which has pushed GPs in the U.K. into the area of disease
management and has possibly compromised holistic
patient-centred health care.

13

THE HUMAN EFFECT IN MEDICINE
Does quality family practice have more to it than just the
management of chronic diseases? Does the relationship
between two human beings have a positive impact in its
own right? Michael Dixon, (2002) in his book, The Human
Effect in Medicine, refers to “a therapeutic outcome to the
relationship between doctor and patient.” He goes on to
say that “For centuries, medical writers and thinkers have
debated the importance of relationships in medicine,
of good communication, and of trust as the basis of the
clinical interaction”. He further states that we should
“forge to aim a new balance between evidence and
philosophy and between professional responsibility and self
care”. The consultation between doctor and patient lies
as the core of this relationship. The bulk of research in the
medical science still lies in the area of bio-mechanics rather
than in relationships between people. Hypocrites said,
“Make frequent visits and enquire into all particulars,
cultivate prognosis that men will have the confidence to
entrust themselves to a physician”. Plato stressed that
the emphasis must be on good communication.
Writers during the renaissance began to stress the
importance of taking histories and listening to the patient,
linking spirituality with human suffering. Alessandro
Beneditti, a physician in Venice in the 17th century, said
that “the human body was created for the sake of a soul”.
The Enlightenment philosophers such as Descartes
introduced the concept of mechanistic thinking through
“Cognito ergo sum”. In the 19th and 20th centuries,
Freud’s contribution developed a vocabulary for the
inter-relationship between doctors and patients and saw
the therapeutic benefits of the doctor. Michael Ballant, in
the 1950s, stressed the importance of listening as a skill,
the awareness of self as a doctor, and the understanding
of the doctor’s emotional reaction to the patient. While
discovering in himself an ability to listen to things in his
patients that are barely spoken, the doctor soon
experiences changes within himself”.
The last decades of the 20th century saw a growth in the
importance of relationships in health care. Deveriche
demonstrated how the death of a loved one impacted
personal care. Other research showed the importance of
stable marriages, happy childhoods, a positive fruitful
relationship with the doctor, and the importance of
managing life events. There was a change in the medical
metaphor. Iona Heath (1995) reported that the three roles
of a general practitioner are interpreting the patient’s story,
guarding against over medication, and witnessing suffering.
Can we define what healing is, or is it just the “placebo
effect”? Hypocrites described the healing capacity of the
patient. Various researchers have tried to quantify the
effect of the placebo. Estimates varied, but some have
reported that it may have an impact as great as up to
30 percent on health. Any pharmaceutical therapeutic
intervention having a 30 percent benefit would be hailed
as a significant medical tool. Do we know the benefits of
alternative therapies? Do we understand self-limiting

diseases and what is the impact of the loss of
empowerment and self healing?
So where have we gone wrong and why is this human
effect so often missing from modern medicine?
Michael Dixon says, “Our intention is to challenge the
dogma of modern technological medicine that ignores the
therapeutic effect of the doctor and the self healing
powers of the patient.” So, we might ask, should we
endlessly fight disease by throwing technology at it,
especially when we are unable to deliver the technology
without frustrating and stressful delays? Perhaps we should
concentrate more on maintaining health and resistance to
disease in the first place. Ballant, in his Utopia (1957), said
of the future, “The General Practitioner will no longer be
able to disappear behind the strong and the impenetrable
façade of a bored, overworked, but not very responsible
dispenser of drugs and writer of innumerable letters,
certificates, and requests for examinations; instead, he will
have to shoulder the privilege of undivided responsibility
for people’s health and well-being and, partly, for their
future happiness.”

MANAGED CARE
Healthline defines managed care as “a system of health
of care delivery that aims to control costs by signing set
fees for services, monitoring the needs for procedures such
as tests and surgical operations, and stressing preventative
care. The Encyclopaedia of Public Health (2001) says that
“managed care is the enrolment of patients into a plan
that makes capitated payments to health care providers on
behalf of its members, thus shifting the financial risk for
health care from patients and payers to providers.” The
intent of this shift is to provide incentives to health care
professionals to reduce their utilization of services, ideally
through measures such as health promotion and disease
prevention among the group’s members.
Managed care grew as a result of the re-organization of
health care in response to economic forces. The rapid
growth of managed care in the USA occurred during the
Reagan presidency. Managed care was provided by
nonprofit organisations, which strove to integrate services
across the three sectors (primary, secondary, and tertiary),
to conserve resources and eliminate waste, encouraging
team work and removing barriers between the levels
of care. It saw the primary care physician as a gatekeeper.
These physicians, however, complained of a loss of
independence and autonomy. Involvement in and
responsibility for financial management could also lead
to possible conflicts of interest.
Managed care has significant strengths. It facilitates
the vertical and horizontal integration of care leading to
the efficient and effective use of resources. It can easily
establish mechanisms within its structure to control
governance, quality, and safety. Physicians and other
clinicians are involved in management and planning.
Managed care’s major weakness is that financial drivers
predominate. Schemes are disease- and

14

population-orientated. There is often a lack of holistic,
patient-centred care, leaving health care professionals
often feeling dis-empowered. So, how can we incorporate
the "human factor" into managed care to ensure that the
traditional values of patient-centred family practice are not
lost? It is my belief that merging the principles of managed
care and traditional family practice can, together,
contribute to better and more effective health care.

AMERICA’S ILLS
In a recent paper in the British Medical Journal (BMJ),
Davies (2007) said that “failure to ensure access to health
care for all lies at the heart of the US failure to achieve
value for money”. The United States is the only major
industrialised country in the world without universal health
insurance. Rather than getting better, the situation is getting
worse. You have a confusing mix of health programmes
and funding options. Major inequalities exist in mortality,
morbidity, access to health, and the quality of care.
Sixteen percent of your population is uninsured and
considerably more is under-insured. This percentage
is rising, mainly in the 18-to-64 year old age group. It is
estimated, according to Davies, that 18,000 deaths per
year are due to lack of adequate health care coverage. The
uninsured are further disadvantaged as health care costs
for them are higher because there is no discounting. They
get poor quality care, poor chronic disease management,
and no regular care. A larger percentage of their care is
accessed through the ER room (35 percent for uninsured,
16 percent for insured) and, finally, significant ill health
can to lead to financial difficulty or even ruin.
The cost of care in the United States is increasing. It is
perverse to think that the cost of filling the gaps in the US
system would be less than the national lost productivity
due to illness and poor insurance coverage. Costs are
continuing to rise. If we look at health care expenditure,
the United States spends twice that of other industrialised
countries yet life expectancy is the lowest of the eight
industrialised nations, in Davis’ study. When we look at
deaths amenable to medical care, only the United
Kingdom seems to have a worse record. Access problems
again show the USA with the worst record and this is even
more stark when we compare access with an open-ended
free service such as in the United Kingdom. Despite the
money spent on health care in the USA, health outcomes
are woeful. Breast cancer survival rates are considerably
worse than the rest of the developed world, as are
myocardial infarction mortality rates. What is equally
worrying is that in a country that boasts the most
sophisticated medical care in the world, deaths from
surgical and medical mishaps are the greatest.
There is considerable discussion as to how Britain and
the United States can share experiences. Chris Ham, in a
2005 BMJ issue said, “The NHS performs as well or better
than the US health care system on many objective
indicators. Yet the United Kingdom shows great interest in

learning from the United States and not vice versa. Is this
paradox a consequence of American insularity, British
credulity, or some other factor, and is there any prospect
of the balance of trade in health policy ideas being
reversed? If so, what aspects of health care in the United
Kingdom should the United States be studying and
seeking help from”? He goes on to say, “In a world where
trade barriers are tumbling, the borders are opening up. A
special relationship between the United States and the
United Kingdom should not blind these two countries to
the opportunities of learning from elsewhere”.
If we look at a simple table comparing the United States
and the United Kingdom, life expectancy is virtually the
same. Yet the United Kingdom spends eight percent of
GDP on health care, whereas the United States spends 15
percent. Satisfaction with the health care system is greater
in the United Kingdom than it is in America despite the
public’s unhappiness with the deficiency of the NHS. In the
U.K., fifty percent of the doctors work in primary care, yet
only 30 percent do so in the United States. The number of
young doctors wanting to become GPs in the U.K. is stable
whereas those applying for family practice residences in
the United Stares continues to drop. There are no cost
barriers to health care in the United Kingdom as there is in
the United States.
What, therefore, can we learn from each other, and can
experiences from other countries fundamentally change
the American system? In the Journal of the American
Medical Association (JAMA), Robinson (2001) said,
“Change at that stage was a long way away. American
people wanted to direct their own health care with clinical
advice from their physician, financial subsidy from
employers and public programmes, information from the
internet and off-line sources, and the support of their
families and friends. Public health initiatives will expand to
the extent that private initiatives contract but the
likelihood of a national, one-size-fits-all programme
becomes more remote with every passing year”.
Speaking with American colleagues, you do get a feeling
that there may be some change in the air. But I remember
being in Seattle when the Hillary Clinton’s reforms were
expected, and there was excitement and expectancy in the
air. That was soon dashed by disappointment. I fear
that we will have great difficulty learning from each other
because our values and our politics are different.
Europeans value a strong central government while in the
United States citizens mistrust central government.
Changes in funding to develop models similar to those
seen in the U.K. would be far too radical in the United
States. Wholesale change is unlikely, but this does not stop
us “cherry picking” from each other. Each country can be
a potential laboratory where we can learn from each other.
Learning, as Chris Ham suggests, is, at present, only one
way. There is an appetite in the U.K. for managed care
programmes such as Evercare, Kaiser Permanente, Group
Health etc.

15

If we are to persuade the USA to look elsewhere, then
what can you learn from the U.K.? Whereas the U.K. can
learn from secondary care in the USA, the strength of the
United Kingdom’s primary care must have some attraction,
especially in the light of the new GMS contract. Initiatives
such as National Service Frameworks for chronic diseases
and vulnerable sectors of the population which promote
quality and safety through the incorporation of evidencebased care must also attract attention. Other organisations
such as the National Patient Safety Agency and the
National Institute of Clinical Excellence aim to provide an
ongoing clinical effectiveness assessment of treatments and
technologies. Finally, primary care computing has seen
significant investment and advances in technology and it
continues to underpin the success of general practice in
meeting the needs of the U.K. population.

HOW CAN WE INCORPORATE PASTORAL
VALUES INTO MANAGED CARE?
To conclude, I have given you a personal perspective of
my practice and my work. I have given the case for strong
primary care and patient-centred family practice. I have
explained how general practice in the U.K. has
incorporated elements of managed care but still, at the
same time, maintains the fundamental principles of
comprehensive, open access, free health care. I have also
discussed the values of the human effect in medicine and
its ability to provide pastoral patient-focused care. Finally,
I have compared our two health systems and extracted
what we can learn from each other.
Is it possible to incorporate pastoral care and values
into managed care? Managed care clearly does have its
strengths. If we can introduce that human effect or
pastoral element, we can deliver effective, efficient,
economic, and humanitarian care into both countries.
We must continue to champion the importance of the
generalist in health care. Only generalists, as McWinney
suggests, can genuinely see and understand the big picture.
By enabling and empowering family physicians, we can
introduce a “bottom up” approach ensuring that
management is never too far away from the patient and the
primary doctor-patient interface. We must improve the
patient experience by adopting patient-centred rather than
disease-focused approaches. Doctors must forge therapeutic
relationships and contracts with their patients and families.
These relationships must maintain patient autonomy, foster
self care, and avoid dependence on the physician.
We need to develop a workforce fit for purpose. The
majority of medical students and other health professionals
will spend their working lives out of hospital and, as a
result, we need to train them in the community when we
can. Learning about the basic biosciences will not be
enough. They will need to learn more about the context of
illness and the impact of social and behavioural pressures
on their patients. The one certainty that I can pass on to

you is that medical technologies, treatments, and health
policy will change, but the values passed on by Hypocrites
stay the same. This is something that we can pass on from
generation to generation. Family medicine will probably be
the best place to do it.
Family practice will also need to change. More care will
need to be provided by bigger and more comprehensive
primary care teams. The family physician will be even more
important as the linchpin that will coordinate care
horizontally and vertically in the future. The family
physician will need to break down the vertical barriers and
work with specialist colleagues to develop integrated care
pathways and protocols. The patient journey must be a
seamless and confident experience. Crucial to this, we
need to establish mechanisms for maintaining quality and
safety for our patients. We will need to work in a
“joined–up” way, working closely with other agencies and
services in local government and the voluntary sector.
We will need to expand academic endeavours in primary
care. It is well developed in some areas but not in others.
Academic growth brings credibility within the profession. It
also fosters critical thinking and research. Research in
medicine has predominantly been quantitative. The science
of caring, relationships, and suffering needs a qualitative
approach borrowing from the research methodologies of
the humanities and social sciences.
Finally, we must not be seduced by technology. Technology
is often merely a tool and has its limitations. I would like to
finish by quoting Michael Dixon. “Our intention is to
challenge the dogma of modern technological medicine
that ignores the therapeutic effect of the doctor and the
self-healing powers of the patient.”
Dr John Wynn-Jones
March 2007

16

Respondent Mary Ellen Bradshaw, MD
Mary Ellen Bradshaw, MD
Consultant, Public Health Administration, Child, Adolescent & School Health
Mary Ellen Bradshaw, a native of New York City, attended SUNY Downstate Medical Center
College of Medicine and completed her pediatric internship, residency and fellowship at
Bronx Municipal/Jacobi Hospital Medical Center. She served as a clinic and school physician
in the District of Columbia Department of Public Health, eventually becoming chief of the
Bureau of School Health Services, a position she held until moving to Phoenix, Arizona, in
1997. Dr. Bradshaw taught School Health and Policy in the Masters of Public Health Program
at George Washington University. She was a delegate to the AMA from the D.C. chapter
for many years. As a delegate, she introduced resolutions regarding the health of children,
adolescents, and women and the practice of medicine. Most of her resolutions were passed
and became AMA policy. Of particular interest is “Towards Preserving the Soul of Medicine,”
a subject close to Mary Ellen’s heart. Less successful were those resolutions directed to
the consideration of a universal health/single payer system. Locally, she has been active in
the Arizona Medical Association House of Delegates and has chaired the Task Force on
Child Abuse and Family Violence Prevention of the Arizona Public Health Association. She
has been a member of the Smoke Free Arizona Coalition. Currently, she is a consultant.

h
I am pleased to have this opportunity to respond to Dr. Wynn-Jones’ impressive
presentation on the intricacies of the medical care system in the U.K.
My remarks will focus on the human factor in the doctor-patient relationship. In
doing so, I will share my thoughts on what medicine is about; my own experiences with
the practice of medicine in the US over several decades; and the issue of relationships,
primary care practice, and community.
A few years ago, when I served as a Delegate to the AMA from the Medical Society
of D.C., I introduced a resolution, “On Saving the Soul of Medicine”, reflecting that
medicine has traditionally been “an art and a science” and that we now are in
the process of substituting business for art. The resolution, which was passed, stressed
the need for all physicians to reflect on the essence of the Hippocratic Oath and to
present a patient-centered, ethical model to young physicians who are being trained in
times of HMOs, when salaries are dependent on the number of “clients/customers” seen
and other economies of scale, but when they all have huge medical school debts.
I have always thought of the practice of medicine as a sacred trust between two human
beings, where individuals place their innermost self and bodies, their very life, in the care
of another human being, who is sworn to do no harm but to heal and comfort. In days of
yore, before many more treatments were available, one of the compassionate functions
of the physician was to sit by the patients and offer succor to them and their families.
So much has changed regarding treatment that what often falls by the wayside is that
still critical component of the doctor-patient relationship, the trust, the X-factor in
healing and comforting, the knowledge that someone is there for you, with your interest
at heart. I believe that it is still the most powerful medicine at our command.
Managed Care, alluded to in the presentation, as I originally understood it, was to assist
in the overall coordination of care for patients—to assist them in traversing an
increasingly complex medical system and bring greater satisfaction to both physician and
patient. Instead, it has devolved into Managed Cost with recognizable benefits to neither.
When there is no time to spend with patients, when we become more absorbed with the
business aspects of keeping a practice going (fighting insurance companies for
reimbursement, having patients change from one provider to another when insurance
coverage changes), we lose that connection, that ongoing trust, that continuity and
familiarity that is so essential to the X-factor of healing and patient care and to the
satisfaction of being a physician. This is one reason so many good doctors are leaving the
profession. The practice of medicine has become another world, estranged from the
reasons we went into what we considered a vocation, a calling to care for others in their

17

most vulnerable moments and to stand with them
through illness and the end of life.

him. He encouraged me to enter medicine, extolling it
as the most satisfying of all professions.

There are at least three, perhaps uniquely American,
phenomena that were briefly mentioned by
Dr. Wynn-Jones. One is the huge problem of lack of
access to routine medical care due to no or insufficient
health insurance faced by about 47 million people
in the US. When care is finally sought, usually in the
far more expensive and overwhelmed hospital ERs,
there has been an increase in the severity of illness. In
these cases, there is essentially no patient-physician
bond, much to the chagrin of both doctor and patient.

I attended medical school in Brooklyn, New York in the
1960s, and was fortunate to have professors who
exemplified integrity, commitment to excellence in care
and respect for patients, who were always to be treated
with dignity, addressed as Mr., Mrs. or Miss, and never
considered as “diseases” or “cases”. I was taught that
taking a complete history was critical—it makes up
85 to 90 percent of the diagnosis. The answer is in the
patient. History came first, then a thorough physical
exam, the formation of a differential diagnosis, and
then, finally, the appropriate lab work to confirm or
rule out diagnosis. All this interaction takes time and
communication with the patient! How far we have
strayed from these concepts!!

The second is the problem of patients with
insurance—the multitude of different policies with
menus of coverage, differing co-pays and deductibles,
physicians being “in or out of plan”, the confusion and
frustration of the patient, and the necessity of a solo or
group practitioner having to hire from two to six
administrative staff just to handle the paperwork with
all the attendant excess costs to the health care system!
The mandatory introductory question of “What type of
insurance do you carry?” does not engender that warm
fuzzy feeling of entering a caring environment.
The third is the ever present and growing threat of
malpractice lawsuits which in the US increases the cost
of liability insurance for practitioners and necessitates
the ordering of every possible test to cover all the
potential bases, which in turn raises the cost of health
care. US health care is the most expensive in the world,
but without the compensatory increases in healthy
outcomes, i.e., life expectancy (40th) and infant
mortality (28th), to mention a few. This tendency to
“sue the doctor” stems partly from the expectation
of perfection, whether it is a baby without defects or a
procedure without complications. But I believe the
tendency is also based, at least partly, on the current
disruption of the patient-physician relationship and
patient anger over the lack of time and attention paid
by the over-scheduled physician. Years ago, one rarely
even thought of suing one’s doctor, not because mistakes
were not made or complications were absent but because
there was a feeling that the doctor cared and was doing
everything possible in the interest of the patient. Doctors
may have been regarded in some ways as gods, but they
were also excused from fault because of their humanity.
My family doctor was a GP, who took overall care of
our family, including relatives from abroad. His
brother, a pediatrician, made house calls when I was ill,
asked about the pictures on the mantel, knew the names
of our cousins in the war—he knew us. Healing was
through knowledge, understanding, reassurance and
the gentle hand on the shoulder.
One July when I was 15, I worked as a receptionist in
his office and learned of his and his brother’s early
history, their love of medicine and devotion to patients.
I learned that re-imbursement was of secondary
importance: When patients could pay, they would pay.
People from all walks of life came to his office and loved

One of the most impressive courses in med school was
Environmental Medicine and Community Health,
where I went to a community health center (public
health) in one of the poorer areas of Brooklyn, saw a
family of four, and followed them clinically doing both
a family and community diagnosis. I visited them in
their home and took note of their living circumstances
which, of course, had an impact on their health
and well-being. I still believe that this type of experience
should be part of every medical student’s
training—placing the patients in their context.
My medical school classmates went primarily into
internal medicine, pediatrics, ob-gyn, psychiatry,
surgery and radiology. Many eventually sub-specialized.
About three of 115 went into general practice.
Throughout future years, the areas of sub-specialization
increased with fewer and fewer physicians even
considering general practice. In the late 60s, the
specialty of family practice started emerging in certain
areas of the country and departments of family and
community medicine were developed. I chose pediatrics.
Other members of my family went into the private
practice of psychiatry and internal medicine and into
preventive medicine and public health, in which the
community is the patient.
After training, I moved to D.C. and became a clinic and
school physician and eventually a public health
administrator as chief of the Bureau of School Health
Services in the D.C. health department. In all of these
primary care and secondary specialties, relationships
with patients and their families proved essential.
Further, in pediatrics and public health, relationships
and involvement with the community (schools, other
agencies and organizations serving children and their
parents) are part and parcel of the job.
Developing legislation, fighting for budget allocations,
testifying before Councils and Boards are par for the course.
Active participation in a variety of professional associations
and enlisting colleagues in support of child- and familycentered initiatives are essential to success. These are
on-the-job lessons learned, not necessarily skills taught
in medical school, although I believe they should be.

18

In sum, there are many primary
care specialties whose core practice is
based on physician–patient
relationships and community
involvement, but these, and the
basic trust inherent in continuity of
care, are being severely disrupted
by the current practices of the US
health care system. Medicine as
“a business” is destroying the soul of
medicine and rupturing the sacred
bond of the physician-patient
relationship, sabotaging the X-factor
so essential to healing, and
disheartening physicians who
entered medicine with the
expectation of a satisfying profession
dedicated to the long term care of
their patients.
In spite of the problems in the health
care system in the U.K., I think we
in the U.S. can take some inspiration
and lessons from the model of
universal access, continuity of care
and humanity of the patientphysician relationship more easily
preserved through a national
health/single payer system that
removes several barriers to caring
and healing.

19

Respondent Jonathan B. Weisbuch, MD, MPH
Jonathan B. Weisbuch, MD, MPH, FACPM
Adjunct Professor, Global Health and Biodesign Institute, Arizona State University
Jonathan Weisbuch received his medical degree from New York University, his Master’s in
Public Health from Harvard, and his Bachelor’s of Science from the Massachusetts Institute
of Technology. He is a Diplomat of the American Board and a Fellow in the American
College of Preventive Medicine. Between 1989 and 2005, he was the director of Maricopa
County Department of Public Health and chief county health officer. Prior to coming to
Arizona, he had been the medical director in the Los Angeles County Department of Health
Services, director of the Department of Health and Social Services of the State of Wyoming,
and state health officer in North Dakota. Currently, Dr. Weisbuch is an adjunct professor at
the Global Health and Biodesign Institute at ASU.
Dr. Weisbuch has had extensive experience as a health officer in environmental health,
a health director in the corrections field and a health resource analyst. He has been
the recipient of the Ben Freedman Award for Excellence in Public Health in 2003 and the
Andrew Nichols Award for Public Health Service in 2002.

h
Thank you, Dr. Martinez- Brawley, for the opportunity to respond to Dr. Wynn-Jones
and Dr. Bradshaw. Each has addressed significant facets of our troubled healthcare
system. Dr. Wynn-Jones has shown how the British National Health Service can
provide quality primary care, incorporating traditional medical values—the
doctor-patient relationship, caring and curing, doing no harm—even though care is
more managed, more technical, and more impersonal than in the past. He suggests that
America can learn from the British experience, which has improved the health status of
Britons under a single payer structure and, very importantly, preserve the valuable
holistic perspectives that family doctors or GPs can provide.
Dr. Bradshaw expanded upon that theme, urging a return to “The Soul of Medicine,”
that trusting relationship between a patient and a physician whose professional
commitment to alleviate pain, repair injury, rehabilitate disability, lessen fear, and treat
illness is the central focus of the craft. Medical practice as a production line designed to
reduce costs at all costs is anathema. Both speakers support human factors in practice
that may not be in concert with the efficient economic management of resources. The
“business of medicine” is caring for individuals, drawing upon family and community
resources as a chief complaint becomes a diagnosis, and then a therapeutic drama
engaging the patient, family, friends and community providers.
Dr. Wynn-Jones has emphasized what we all know: Our excessive costs, high technology
and array of medical specialists have failed to achieve the national health status that
every other advanced nation has reached at much lower cost. The decline in primary
providers in America to 25 percent of graduates as compared to 35 to 40 percent in other
Western nations further exacerbates higher costs, reducing prevention and public health.
While alluded to, but not discussed in detail by either speaker, the decline in public
health resource is ironic, since nearly all improvements in community health status
(lowered infant and maternal mortality, longer life expectancy, improved food and drug
safety, and declines in occupational and highway trauma, dental caries, heart disease,
stroke, and now lung cancer) are due to public health interventions in the past century.
And gaps in these data between America and other developed nations will continue
unless major investments in public health and primary care occur.
To return to a compassionate system, the “soul of medicine,” described by Drs.
Wynn-Jones and Bradshaw, public policy must change. Our focus on cost containment
in clinical practice must evolve toward a policy of reducing the total social cost of poor
health by increasing access to care for everyone. We must also address eliminating the
factors in the environment, our culture, and our biology that promote disease, disability
and death. Raising the health status of the nation benefits everyone. But tweaking the
current system to encourage “better consumer choices,” tighter controls over medical
practitioners, and the further expansion of private insurance benefits only a few. The

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strategy I recommend would increase resources allocated to public health and create a
single payer reimbursement system akin to those in Western Europe, Japan, or Canada.
Figure 1 depicts the costs and relationships associated with various elements in the US
health care system. Public Health (PH) serves virtually everyone in the population.
Pre-hospital care provides emergency transport about 15 million patient trips annually.
Annually, one billion primary care visits generate another 300 million referrals to
secondary care specialists. Secondary care, both ambulatory and in-patient, consumes
20 percent of medical resources; tertiary care another 30 percent. Long term care,
nursing homes, and specialty hospitals (rehab, mental health, etc.) serve the critical
needs of a relatively small number (2 to 3 percent of the population); home care and
other community-based services constitute a small, but important, part of the system.
Nearly 40 percent of costs occur in the hospital setting; 23 percent reimburse physician
visits (primary and secondary care). In the United States, prescription drugs consume
11 percent of the total. In 2005, an estimated $2 trillion was spent in the health system,
30 percent being administrative overhead. Increases in public health and prevention
will reduce risk factors that promote disease. A shift from the employer-based,
pluralistic clinical reimbursement system will reduce overhead expenses to the 5 percent
consumed by Medicare (excluding Part D).
Strengthening public health and changing the reimbursement
system for clinical care will improve health status and reduce
costs, provided the plan includes several items:
• Funding must support public health infrastructure
expansion, not just preparation for bioterrorism attacks.
• The system must assure access to clinical care for
everyone irrespective of income, race, employment, or
immigrant status.
• It must provide adequate reimbursement for primary
providers, encouraging their increase through incentives.
• It must balance the economic value of specialty care
against the necesity for primary care for everyone, a
principle that may require increasing the fees for family
physicians, internists and pediatricians, and diminishing
reimbursement for super-specialists.
• And, last, hospital compensation must assure an adequate supply of beds, nursing
coverage, a reduction in nosocomial and iatrogenic illness, technologic improvement
and capital investment, while limiting non-clinical administrative overhead.

Radical change of this type may not occur at the federal level, but innovation among
states is possible. Several bills pending in State Houses across the nation may initiate
this trend. The California Kuehl Bill will grant everyone in California access to medical
care, reimbursing all private sector costs through one public agency. In Arizona, a
similar bill has been introduced. Vermont and New York are developing similar plans.
When any of these bills become law, overhead in that state will decline, as will the cost
of drugs. As primary care expands to serve everyone, excessive emergency room use for
non-emergent problems will diminish and preventable problems will be identified and
treated. Practitioners will no longer need to ask, “Who is your insurance provider?”
In summary, Dr. Wynn-Jones recommends that America examine delivery systems in
the United Kingdom and in Europe, and incorporate into our managed health system
the principles of expanded primary care, an enhanced family and community
orientation, and a focus on preventing disease rather than high-tech treatment. Dr.
Bradshaw urges the return to the art and science of medicine as a caring profession, not
a business that buys and sells technical services. These recommendations will not be
achieved, however, unless we expand our investment in the public’s health, guarantee
the right of health and health care for all, and reorganize reimbursement so that our
pluralistic system with its complex administrative bureaucracy is eliminated.
Winston Churchill once quipped, “America always does the right thing, after it has
tried everything else.” Now is the time for us to do the right thing.
© 2007 Arizona Board of Regents, 07.181
Editor Emilia Martinez-Brawley, Technical Editor Julie Riddle
Graphic Design Chrys Gakopoulos, Deanna Johnson, Randy Irvine
Photography Chrys Gakopoulos, Jim Patzer, Margo-Rivera Wilson