Letter From London

I’ve just returned from a few days in London, scoping things out for a planned sabbatical next fall. In what may be a pale echo of the late Alistair Cooke’s always fascinating “Letters From America,” here are a few of my initial observations:

The dominant issue, of course, is the Cameron government’s new austerity program, with its planned deep cuts to government services and benefits. While the program (or programme, I guess I should say) has created some upheaval – witness the recent semi-violent demonstrations by university students, whose tuitions may treble – it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America. My sense is that the relative acceptance (yes, I know Charles and Camilla had a frightfully awful limo ride to the West End the other night, but this was, er, theater rather than a defining moment) can be explained the Brits’ stronger trust in their government. It is this same trust that leads to near-universal support for the National Health Service, the UK’s tax-funded healthcare system. This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”

In the US, of course, there is no such trust today, nor harbingers of its return any time soon. In a recent issue of Time that outlined this past decade’s mega-trends, Nancy Gibbs observed that the cumulative effect of 9/11, Katrina, BP and the subprime crisis was to markedly shrink Americans’ already scanty faith that their government can do anything competently. So our response to the recent announcement that Chinese kids are shellacking us in educational achievement is hand wringing and statistical nitpicking, not the call for vigorous government action that characterized our nation in the Sputnik era.

Moreover, in the US, our skepticism about government has been amplified by something even stranger: a profound and growing mistrust of elites. By elites, I’m not referring to the “moronic wealthy,” as one of my new English friends described the archetype personified by Dudley Moore’s character in “Arthur.” No, in the UK, I’m referring to the Cambridge/Oxford intelligentsia, who wield disproportionate power in the halls of Parliament. There is little sense in England that the government would be well served by replacing these elites with “real people.” On the other hand, in today’s America, being an educated Ivy League grad is seen as a liability (healthcare’s Exhibits A and B are those brilliant Harvard professors, Drs. Berwick and Blumenthal). The counterpoint, of course, is Sarah Palin (whom the British were endlessly curious about). As Frank Rich recently observed when discussing Palin’s seemingly unstoppable circus act,

What might bring down other politicians only seems to make her stronger: the malapropisms and gaffes, the cut-and-run half-term governorship, family scandals, shameless lying and rapacious self-merchandising. In an angry time when America’s experts and elites all seem to have failed, her amateurism and liabilities are badges of honor. She has turned fallibility into a formula for success.

The UK’s healthcare issue of the moment is the decision by the government to completely upend its system of Primary Care Trusts: an 8-year old program that created regional, professionally-managed entities to receive and then dole out fixed budgets to purchase healthcare for large populations of patients – sort of like our HMOs, but funded with tax dollars. The decision to pull the plug on the PCTs is a very big deal: today, they manage 80 percent of all NHS funds. Faced with rapidly rising costs and some scandalous instances of service and safety lapses, the coalition government decided not to tweak the Trusts but to scrap them entirely. The solution, to be implemented over the next 2-3 years: replace the Trusts with consortia run by General Practitioners, England’s version of our primary care physicians.

This is interesting, since, as my businessman father always drummed into me, God has not invented a class of people worse at running businesses or investing money than doctors. But, as one British physician-leader told me over a delightful pub dinner, the Cameron government came to believe that the only way to get a subspecialist to think about adopting a less expensive practice style – for example, pushing expensive chemo on a patient with little time left – was to create an environment in which another physician, not a manager, was the one to tap the oncologist on the shoulder and ask him about the appropriateness of the full court press. “To catch a thief, know a thief,” quipped my colleague. GPs are said to be ambivalent about the new responsibility they’ll soon be assuming. Some seem pleased about the infusion of power and money; others prefer to stick to their knitting.

In Great Britain, it’s the knitting that pays for GPs. These physicians are not the same downtrodden and status-challenged group as PCPs are in the US: a senior GP can make $300K/year, substantially more than the average specialist! It’s hard to imagine, but many medical students in Britain choose primary care careers for the money.

I don’t know enough about Britain’s new GP commissioning plan or the overall deficit reduction scheme (which the government has euphemistically labeled the “Big Society“) to decide whether they are good ideas. But what strikes me most about both initiatives is the public’s acceptance, seemingly, of rather staggering degrees of transformation. In the US, this would be the equivalent of our Congress signing onto the Simpson/Bowles deficit reduction plan, or a similarly ambitious plan to combat global warming – inconceivable, as our fractured political system would not allow change that ambitious. Creeping incrementalism R Us, for better or worse.

Mostly worse, I think.


I’ll be in England, studying patient safety with Prof. Charles Vincent and colleagues at London’s Imperial College, from next June to December. I’ll share additional thoughts with you as I learn more about their system – and, with the perspective on one’s own world that only distance can afford, about ours.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

5 replies »

  1. Bob,
    It really isn’t terribly complex. The majority of Brits are in the economic lower classe of a two classe system. It’s not that they trust their government, it’s just that they have little ability to influence what the social and political elite control in Parliament!
    Why would they care whether a bureaucrat in a PCT manages the budget or a PCP manages the budget, as long as they get their free care? Britain has had free managed care for almost 60 years. Since joining the EU care can be accessed through any member country’s health system. Some of it works well, and the part that doesn’t is accepted as the result of a free entitlement programme. In the 90’s, there was a good bit of disgust over hospital waiting lists for elective procedures lasting up to 18 months, the Blair government sought to resolve some of the ineffeciencies, and with the opening up of EU markets to pick up the slack the biggest complaint went away…and not because the government or populous had anything to do with it.
    PCTs were doomed from the start. The resources and management were never in place to more tightly manage care even though BUPA, Humana and others had set up shop to help the PCTs with HMO-like information products to better manage populations. A wise person once told me that “a new organization chart didn’t matter if people wouldn’t work together.”
    So, with the new reductions in the Cameron government, healthcare actually does OK, compared to defense and education. When/if the cuts come to the NHS and services are reduced you may hear a bit more noise, but it won’t be by the students who have yet to realise the benefits of universal healthcare, it will be from the quiet and more reserved aged populous who still respect the upper classe…, not because they trust them, but because they are subordinate socially and economically.
    One thing that you should try hard to learn during your sabbatical is about the significant societal differences that make countries unique. Some of that rolls over to healthcare and is important to comprehend as you contemplate whether nationalised healthcare could ever function in America. One size doesn’t fit all, and our particular size is one of the reasons we emigrated to America in the first place! Having spent several sabbaticals both in the UK and on the continent, I can say that if you embrace the entire society you will find it most fulfilling. Bon voyage.

  2. No one is more of an elitist than Palin. She openly believes that even though she’s never studied or understood or achieved anything in important fields, she already knows better than the trained experts. She might as well say she knows better than you what your favorite food is.
    Luckily, Palin is not popular at all–she is actually one of the most unpopular American political figures, beloved only by a weird fringe on the farthest right. Her proclamations from her Twitter dollhouse reveal nothing about America. She’s just along for the ride, like any other grifter.

  3. I have to agree with Nate on this one(!)
    Palin is an anti-science twit, and a quitter. She’s a poster child for “fail upward.” However, Obama’s actual performance in office has been sorely lacking. His connections to shady people and their influence on his policies is extremely disturbing/disheartening to say the least. Would Palin be so much worse than Obama? I honestly don’t know any more.

  4. She quits the governor race after getting tired of BS lawsuits and she is blamed for cut and run.
    Obama quits his senate seat weeks into getting it to campaign for a job he swore he wasn’t running for then takes the new job when he wins the election and the elite don’t say a word?
    And you wonder why we tell the elite to shut up and spin on it?
    Family scandals…like mob connections? Shaddy land deals? illegal relatives on the public dole? Terrorist best friends? No word from the elites on those issues.
    Curious what the point of even invluding the palin bash was except to point out your liberal credentials? Wanted to make sure everyone knew you were one of the elites?
    you take what is otherwise an interesting personal observation about going ons over the pond and turn it political for what purpose?