[The national health service in the United Kingdom-past, present and future].

Britain's National Health Service (NHS) came into existence in 1948. It was the first comprehensive health system in any Western society to be based on the national provision of services and to offer free medical care to the entire population. The NHS has gone through several developments since, in particular the reorganisations of 1974 and 1982 and the general management overhaul of 1984. Until 1991, however, the NHS kept to the following principles: health service for everyone; sharing of financial costs and free at the point of use; geographical equality; the same high standard of care for everyone; selection on the basis of need for health care; and encouragement of a non-exploitative ethos. Britain's achievement with respect to health care has generally received high praise. Nevertheless, Mrs. Thatcher's government was convinced that the NHS contained a number of serious weakness. This view sprang from the government's belief that, because the NHS did not have a competitive market structure, it lacked an incentive for efficient behaviour. The reforms that were introduced in 1991 were designed to overcome these perceived flaws by creating a limited or internal market in health care, in which multiple providers of services compete with each other for the custom of independent purchasers. Competitive pressures now focus greater attention on patient needs, and the separation of purchasing functions has placed resource allocation under greater scrutiny. Making hospitals financially dependent on general practitioner (GP) referrals has resulted in consultants establishing closer contact with GPs. More is being done in GP surgeries and this has the effect not only of widening the range of general practice but also of raising GP standards. However, there are also some internal problems. Administrative costs have increased steeply, and new inequalities are developing as a consequence of competition. To reduce management costs and to allocate as much of the NHS budget as possible to direct patient care, the government produced and made public its plans for the future structure of NHS management in 1993 and a simplified structure is expected to go into effect by 1996. The Labour Party's document on health and health services in Britain was made public in 1994. The plan rejects the use of competition in the NHS and promises to reverse recent developments, reasserting the importance of the original principles of the NHS. It is too early to reach a verdict on the British experiment. Given the direction of change in Labour's thinking and the fact that the current reforms by the Conservatives are becoming more and more firmly embedded, almost anything is possible.

[The effect of professional dental health care in the prevention of periodontal diseases in adults].

Dental health conditions of participants in adult general health examinations provided as a health service by a local government from 1983 to 1987, were analyzed to evaluate the effect of individual dental health instructions with prophylactic treatment (individual instructions) for preventing periodontal diseases. For this purpose, Periodontal Index (Russel) and Debris Index (Greene & Vermillion) of 557 dentate adults aged 40-59 were examined. In the group that received individual instructions, average PI showed a significantly greater decrease during the period from the first inspection in 1983-1986 to the last one in 1987, compared to the group that received no individual instructions. For those with PImax greater than or equal to 6 at the first examination in 1983-1986, the figures of average PI showed a significantly greater decrease in those receiving instruction than the group that received no individual instructions. Between 1983-1987, the proportion of persons with PImax greater than or equal to 6 decreased from 74.2% to 27.3% as a result of the individual instructions. The figures for average DI showed significant changes but, no significant difference was observed between the two groups.

[Analysis on the relationship between use of health check ups and medical care by elderly patients. A study on urban cities with high health check-up rates].

The aim of this study was to evaluate the influence of health examination provided by municipalities in Japan on the use of medical care by elderly patients aged 70 and above. The study was carried out to compare health indicators of cities with high and low usage rates for health check ups over 14 years. The indicators of health service utilization included mean bed days, mean inpatient fees, and mean outpatient fees in 1983, 1988, 1993 and 1996. The data for these indicators were collected from all 12 Japanese cities, where more than 50% of the target population had annual health check-ups in 1983, 1986, 1989 and 1992, as the subjects of high rate cities. All other 134 cities belonging to the same prefectures with the 12 cities were included as the control low rate cities. The correlation coefficients for all the 146 cities showed that usage rates of health check ups had an inverse relationship with mean bed days and mean inpatient fees for the elderly population in all the fiscal years 1983, 1988, 1993 and 1996. In nine out of the ten prefectures, mean bed days and mean inpatient fees were lower in the high rate cities as compared to the low rate cities for all the fiscal years compared. The bed days in the 12 high rate cities were 72% of those in 134 low rate cities in 1983, and the percentages were 66%, 72%, and 78% in 1988, 1993 and 1996 respectively. No remarkable differences in mean outpatient fees were observed between the high and low rate cities. The differences in use of medical care by inpatients suggest that providing preventive health services would decrease the demand by the elderly and result in a more efficient use of health resources.

[Pulmonary thromboendarterectomy for chronic pulmonary thromboembolism in three patients with systemic lupus erythematosus and antiphospholipid syndrome].

Pulmonary hypertension (PH) is a serious and often fatal complication of systemic lupus erythematosus (SLE). Several potential mechanisms have been postulated for narrowing of vessels as a result of pulmonary vasculitis and pulmonary thromboembolism caused by antiphospholipid antibodies. Pulmonary thromboendarterectomy for chronic pulmonary thromboembolism is performed to alleviate pulmonary hypertension. We report three rare cases of SLE with antiphospholipid syndrome in patients who presented with PH secondary to chronic pulmonary thromboembolism. Pulmonary thromboendarterectomy was performed, and all patients remained well without deterioration of PH after surgery. Pulmonary thromboendarterectomy should be considered as an effective method of treatment for this disease.

[Acute fatal pulmonary embolism: its prevention, diagnosis and treatment].

Acute fatal pulmonary embolism is one cause of sudden death which should be guarded against. It is the most often missed diagnosis in sudden death cases within the hospital. Clinical pictures of 10 patients with acute fatal pulmonary embolism proved by autopsy were examined to elucidate the problems of diagnosis, and to look for an effective treatment, and a method of prevention. Common risk factors were old age and immobility due to stroke or postoperative state. Common past histories were hypertension, diabetes mellitus, obesity, atrial fibrillation and hyperlipidemia. Electrocardiogram and echocardiogram showed that in these patients there was definite evidence of acute right ventricular overload. High doses of intravenous urokinase should be given whenever acute cardiovascular collapse develops in such high risk patients. Emergent pulmonary angiogram and pulmonary embolectomy could be life-saving in patients with acute massive pulmonary embolism. Prevention is, however, the best treatment. In addition to anticoagulation medication, frequent change of body position and early mobilization are important precautions to prevent fatal pulmonary embolism developing in such patients.

Relationship between preventive health services and use of inpatient and outpatient care by residents aged 40 or older in 44 municipalities in Osaka Prefecture, Japan.

We examined the relationships between preventive health services provided under the Law for Health and Medical Services for the Elderly and the use of inpatient and outpatient care by insured residents aged 40 or older covered by the National Health Insurance in 44 municipalities in Osaka Prefecture. Factor analyses showed that hospital admission rate and inpatient days per 100 insured persons, bed days per insured person, inpatient days per case, mean bed days, the proportion of long-stay (180 days or more), and the rate of long-stay per 1,000 insured persons accounted for the first factors of inpatient care with factor loadings of more than 0.82. Outpatient utilization rate and outpatient days per 100 insured persons comprised the first factors of outpatient care with factor loadings of more than 0.80. Patient cost per case and the proportion of high patient cost (600,000 Yen or more for inpatient care and 60,000 Yen or more for outpatient care) made up the second factors of either type of patient care with factor loadings of more than 0.87. The frequency of use of health check-ups and the numbers of instruction classes and participants in health education and health counseling per 100 residents showed negative correlations with indices of inpatient and outpatient care, except for patient cost per day. The scores for the first and second factors of inpatient care and for the first factor of outpatient care correlated negatively with all indices of the use of preventive health services. More active provision of preventive health services may therefore contribute to reducing the subsequent use of inpatient and outpatient care among residents aged 40 or older.