By Richard Hoey

When British Prime Minister David Cameron defended his reforms of the National Health Service against a series of aggressive attacks from critics this week, he fell back on a familiar argument – that his reforms  would hand control from bureaucrats to clinicians. But the reforms don’t, in fact, hand power to clinicians generally – they hand responsibility for commissioning in the NHS largely to general practitioners (GPs), our answer to US family practitioners. I think it’s worth spending a bit of time explaining quite why, because as other bloggers have written on this site, US policy experts often find it surprising that in the UK such a high status is afforded to family medicine.

GPs in the UK often earn more than their specialist colleagues, and they do so because they have a much more central and wide-ranging role in the British NHS than family practitioners do in the American healthcare system. GPs are in traditional terms, the gatekeepers, and in updated terms, the navigators for the NHS. Patients can’t simply book themselves in to see a hospital doctor – the great majority of first contacts with the health system are with the GP practice. GPs are highly trained, following their medical degrees with two foundation years and then three years of specific GP training (with pressure to extend that to four or even five years).

Although they’re generalists, the profession is regarded as a specialism – and its expertise is measured partly by its ability to manage as many patients as possible in primary care, without the need for referral to hospital. GP care has proved highly cost-effective, both by controlling the numbers of patients who access expensive hospital treatment, and by directing patients to the most appropriate part of the NHS when they do need specialist attention. And in an NHS facing unprecedented cost pressures, that’s given them an enormous amount of power, and is about to gain them a whole load more.

Continue reading “Minders of the Gap”

By BOB WACHTER, MD

I’ve heard a lot of shocking things since arriving in England five months ago on my sabbatical. But nothing has had me more gobsmacked than when, earlier this month, I was chatting with James Morrow, a Cambridge-area general practitioner. We were talking about physicians’ salaries in the UK and he casually mentioned that he was the primary breadwinner in his family.

His wife, you see, is a surgeon.

This more than any other factoid captures the Alice in Wonderland world of GPs here in England. Yes—and it’s a good thing you’re sitting down—the average GP makes about 20% more than the average subspecialist (though the specialists sometimes earn more through private practice—more on this in a later blog). This is important in and of itself, but the pay is also a metaphor for a well-considered decision by the National Health Service (NHS) nearly a decade ago to nurture a contented, surprisingly independent primary care workforce with strong incentives to improve quality.

Appreciating the enormity of this decision and its relevance to the US healthcare system requires a little historical perspective.

As I mentioned in a previous blog, the British system cleaves the world of primary care and everything else much more starkly than we do in the States. All the specialists (the “ologists,” as they like to call them) are based in hospitals, where they have their outpatient practices, perform their procedures, and staff their specialty wards. Primary care in the community is delivered by GPs, who resemble our family practitioners in training and disposition, but also differ from them in many ways.

Continue reading “The British Primary Care System and Its Lessons for America”