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.