Health Care Reform in the U.K. and U.S

“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996,  such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Accountable Care Organizations (ACOs)
In the U.K. regional Primary Care Trusts (PCTs) have been responsible since 1948 for “commissioning” (purchasing) care beyond primary care; hospitals, specialists (consultants), ambulance service, maternal health. GPs advised these trusts, but did not run them. By 2013 they will. 141 GP Consortia will commission (purchase by contract) all patient care services for a defined population and will control the allocation of 80% of the NHS budget. Secondary care providers (hospitals and consultants/specialists) will be competing on quality grounds for the contracts. Prices will remain regulated nationwide by the NHS. Sounds like a physician-run Accountable Care Organization (ACO) doesn’t it? (Remember 50% of U.S. medical care services are currently paid for by our government; Medicare, Medicaid, VA, or Federal Employee Health Benefits).

Medical Home
Since most GP practices have been closely connected for years with visiting home care nurses, social workers, and other ancillary social services through the Local Health Authority and every patient needs to “register” with a GP, GP practices closely match the newly-coined U.S. definition of “A Medical Home”; i.e. a multidisciplinary primary care unit that manages, but does not provide, all aspects of the patient’s care. Now the GP referrals will more directly affect the flow of money.

HIT Investment
A multi-million dollar program started in the U.K. in 2003 to develop digital patient records and hospital administrative systems outsourced to two national major vendors its imhas been poorly implemented  . The new plan calls for incentives for more local and regional initiatives from the Trusts/Consortia to move HIT along.
“Improving IT is essential to delivery of a patient-centered NHS”..a modular approach based on”connect all” rather than “replace all”.
The government proposals call for an NHS-wide “information architecture” set around standards, improvements in data accuracy, and the opening up of records to patients online. The NHS looks to saving $32B (billion) by 2015 by implementation of the revised HIT plan. There is a concern about the Trusts/Consortia having enough HIT expertise to do this is. In the U.S. the establishment of 70 Regional Extension Centers and HIT Workforce Development Grants will help implement the “meaningful use” of HIT. Neither the U.K. nor the U.S. plans have established national standards for connectivity; standards that need to be “transparent and centrally mandated” to reduce complexity. This lack of connectivity will be an increasingly vexing problem for both providers and patients in both countries.

Bottom line: Both U.S. and U.K. are evolving toward a similar mixture of public/private health care schemes from their different historical directions. They share common objectives and common problems., and neither country is finding the path to be particularly smooth. Since EVERY country’s health care system is different, and critics of health care reform on both sides of the Atlantic are whipping up fear of the “other system”, it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.

1. Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.
2. David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B., “British Lessons on Health Care Reform” , September 9, 2009, at NEJM.org
3.Wachter R, Goldman L. “The Emerging Role of ‘Hospitalists’ in the American Health Care System”. N Engl J Med 335 (7): 514–7. 1966

Herbert Mathewson, MD, blogs at HUB’s LIST, a compilation of medical fun facts gleaned from a variety of medical journals, newspapers, other public and professional sources, and an occasional private communication.

21 replies »

  1. is telehealth as regualted in the UK as it is here? Are any of the GPs in the UK doing their own telehealth or is it adveseral like here?

  2. Idealogical ranting aside, I have been kind of fascinated to watch blowing up the Primary Care Trusts without really having more definitive guidance from the NHS on how this is supposed to work. No offense to the doctors who might read this but they often don’t make the best businessman.
    My bet is that the new GP Consortia will generally have the same experience of physician organizations that formed in early-mid 90s in the US. A few really will be capable of dealing with the changes in structure & payment but most will largley waffle.
    Just like in the US, I don’t see where the additional capital outlays are going to come from to really support the staff and instructure needed to make these organizations work as designed/touted.
    Unlike the UK hospitals which generally have really low rates of IT adoption, most of the GP offices are wired with EMRs (the UK equivalent) & this market is much much more concentrated and consolidated among 3-4 vendors that vary from region to region. EMIS, TPP, INPS (CEGDEGIM), and iSOFT have a 85-90% market share in the GP offices with EMIS the clear leader.
    GP Consortia though will be struggling with the same issues that US Hospital CIOs are struggling with where there is a relatively high degree of ambulatory EMR penetration in their community. How do you integrate all of this stuff and then incorporate other necessary pieces (e.g., rehab, imaging center, labs) as necessary?
    Some of the usual players in the US market are making a strong push to bridge this gap but there are a ton of small market cap UK health it companies especially in the telehealth monitoring/community space. Really interested to see how it plays out both in the UK and in the US.
    While there are some similarities, there are just as many important differences too especially in regards to UK IT adoption and the nature of the marketplace compared to the US.

  3. I shouldn’t be surprised you just don’t get it. You liberals never do grasp how to set up accurate analysis. Have you ever heard of a State school district? Schools are managed at the county and city level. A Red State has no bearing on how badly the democrats at the county and city level run it.
    Care to dicuss the subjective nature of your link? Going to college means your more educated, despite the recent realization that a large portion of our college education is wasted and of no value. A kid out of school going to work to learn a trade who then starts a business is considered less educated then a women’s study major waiting tables.
    That Peter is why liberals are idiots and ruin everything they manage.

  4. “Peter might want to check your facts, its the Democrats that keep the poor uneducated.”
    Facts: http://topalli.com/blue/
    Education achievement does have a lot to do with poverty level, but the above link (click on Education, or anything else you want) shows that Red States do a lot worse. Democrats in Red States are just Republicans in sheep’s clothing.

  5. Peter might want to check your facts, its the Democrats that keep the poor uneducated. DC schools, Baltimore Schools, LA Schools, etc etc, what exactly do conservatives have to do with those failures?
    if you don’t pay taxes or you pay low taxes how do we not save money? That makes no sense.
    Your other complaints are just made up blabber, obviopsuly not sure what your trying to say which makes it really hard for anyone else to guess, that happens when you talk in sound bites and don’t understand the issues and facts.

  6. “I want liberals to stop claiming we can save money by preventing illness.”
    Would that include public health for communicable diseases?
    I want conservatives to stop claiming we can save money by no/low taxes, allowing pollution, not addressing global warming, keeping the poor un/poorly educated, building jails, denying healthcare access to millions of citizens, ignoring obesity and lifestyle health issues, deregulation.

  7. While good primary and preventive care can help to keep people healthy, lifestyle choices, low socioeconomic status and bad genes are likely to be much more important factors in how long we live. In my opinion, though, it’s not lifespan per se that’s important, it’s health span.
    Those who make it to old age are far more likely to develop Alzheimer’s and dementia which can last for years and can be very expensive to treat, especially if long term custodial care is ultimately required. Cancer is also more common among the elderly which is expensive to treat as well. As our bodies start to wear out, we can develop heart failure, kidney failure, and COPD among other diseases. The point is that very few of us are healthy to the end and then die quickly and cheaply from a medical cost standpoint. Currently, about 33% of medical costs are incurred by the 65 and older population though they account for only about 16% of the population.
    In a perfect world, aside from childhood immunizations, maternity, labor and delivery, normal checkups and preventive care, all medical costs would occur in the last year or two of life and we would all be perfectly healthy until then. What and how much care is appropriate at the end of life is an important issue but a whole separate discussion.

  8. I want liberals to stop claiming we can save money by preventing illness. Rather we have diabetics or not we need honest facts, no more liberal promises that 60 years later threatens to bankrupt generations.

  9. “A non compliant diabetic that does early cost the employer plan and saves the tax payors. A healthy person saves employers money and cost taxpayors.”
    So you’re just interested in employer costs and not taxpayer costs? Do you want compliant diabetics or not? I guess you want compliant diabetics that will never collect their pensions which save employers AND save taxpayers? Now there’s an election platform for healthcare/pension reform.

  10. perhaps my point was to suttle peter, private business is a very large, diverse, aggreagtion of interest. You didn’t say cattleman would oppose it you said all private businesses would, which obviously is false. I know you want to demonize all private enterprise in your quest for socialist nirvana so I just point out the mistake. Just like all insurance companies aren’t bad etc etc.
    A non compliant diabetic that does early cost the employer plan and saves the tax payors. A healthy person saves employers money and cost taxpayors.

  11. “Why would organic growers not want government involved or gyms, wellness organizations, I can think of thousands of businesses that would want more government regualtion/exposure.”
    Paying for those programs would involve taxing unhealthy foods and/or unhealthy behavior and taking away subsidies, not something the cattlemans association or the processed/fast food industry would support. As well there’s no upside for organic growers to advocate for that. Usually people conscience about their health also fight pollution, but well lobbied industry usually get their way. Oh that organic/local growers had 1/10 the political power large food processors/retailers have.
    “The problem is defined benefit not defined contribution plans.”
    I assume you are referring to government/union pension plans. There is still a connection to employee/employer contributions over time and amount of defined benefit at the end. These are negotiated contracts. Why would anyone want to invest in a pension where the payout/accumulated contributions is in jeopardy, especially when governments will then steal from pension contributions/accumulated investments to balance budgets as an easy way to not face fiscal responsibility. Here in NC typically every time there is a meager pay raise for government workers the state raises their health benefit contributions as claw back. Fiscal irresponsibility here also means robbing peter to pay paul in a political game of hide the ball.
    “A diabetic dieing at 60 is far cheaper then a healthy person dieing at 90.”
    How would a healthy person die or even need health care, that’s not a definition of “healthy”. I guess it depends on how long the diabetic has the disease and what complications develop. So would you promote as unhealthy a lifestyle as possible to hasten death? I remember you had complained about a “non-compliant” diabetic in one of your groups, wouldn’t a “non-compliant” die sooner?

  12. “all the things private business does not want the government involved in.”
    Why would organic growers not want government involved or gyms, wellness organizations, I can think of thousands of businesses that would want more government regualtion/exposure.
    “Pensions would be a different problem, but as with all pensions, payouts depend on years and amounts of contributions.”
    The problem is defined benefit not defined contribution plans.
    “Anything you can do to reduce chronic disease rates should help,”
    Not should it will help raise life expectancy which increases total cost considerably. A diabetic dieing at 60 is far cheaper then a healthy person dieing at 90. Which is not to say we shouldn’t be helping people live to 90 but don’t sell it as a money saver. That is how you create trillion dollar unfunded liabilities like Medicare and SS.
    If we are to invest consider money in wellness and preventive care then we need to invest 100 times as much in additional Medicare and SS taxes. Compare 25 years of inflation adjusted SS benefits and Medicare cost to 20 years of diabetic treatment in current dollars. And remember private insurance, which is far more efficient then government care, is providing the 20 years of diabetic treatment. Your talking about shifting/adding trillions of liability onto tax payers and want to claim budget reduction while doing it.

  13. Exactly what Peter said….
    Anything you can do to reduce chronic disease rates should help, and anything you can do to keep chronic disease controlled should help tremendously. I think the trick is to keep folks out of hospitals as much as possible, and if they live longer without hospitals, you may lose a little bit of what you gained, but not all of it.

  14. Nate, I guess the point is to keep people from getting treatable chronic disease. Paying for 30 years of disease is going to be more expensive than paying for 10 years. Not sure you want an age cutoff for care. We’d have to pinpoint what’s making people sick; I think mostly lifestyle, food and pollution/contaminants, all the things private business does not want the government involved in. Pensions would be a different problem, but as with all pensions, payouts depend on years and amounts of contributions.

  15. Margalit spending more on healthy people to keep them healthy keeps them alive longer which cost considerably more. Not only in healthcare but social security pension and other expenses. If we already have a major budget shortfall how is another 50,000 100 year olds going to help?
    Your using a cost argument to justify increasing cost while saying you want to save money?

  16. “Both countries are seeking to reduce costs”
    No, the U.S. has yet to attempt to reduce costs, it does however want to shift costs to patients and premium payers.
    “In both countries the majority of patients are highly satisfied with the NHS or Medicare”
    Not so much satisfied with care outside Medicare.
    “Prices will remain regulated nationwide by the NHS”
    Too bad we don’t have that here.
    “it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.”
    I’d take either, but you know, we’d all have to be insured for these systems to work – something not in the Republican non-plan. Republicans aren’t known for “expanded vision”.

  17. MD as HELL, you are consistently pointing to over utilization by the “worried well” as the biggest problem we have. However, all studies show that most health care dollars are spent by a small group of very sick individuals while the vast majority of Americans spend next to nothing on their care.
    Shouldn’t we just concentrate on those high-utilizers, with multiple chronic diseases, and see if we can reduce their numbers by spending more on healthy people to prevent chronic disease, and perhaps provide the very sick with better, and more primary care based, care?
    Instead of nickeling and diming those who want to see a doctor for a cold, wouldn’t massive intervention for the very sick, coupled with long term investment in lifestyle changes, be a wiser approach to higher and faster ROI?

  18. The U.S. has patient-driven discretionary spending, driven by the worried well and the failure to enact tort reform. It does not add at all to quality or change outcomes.
    The private payors have a better grip on this spending than the feds, but it is still a runaway train.
    The other developed nations’ citizens never have had the freedom to spend like Americans have. They never had to take as much away as this country must to create a sustainable system.

  19. Interesting that you find so much commonality in two very different systems. How does the UK manage to keep people healthier than the US while spending less than half of what the US spends?
    I agree that we should look to other countries (i.e. every other developed country) who manage to provide better health to their population than the US… all at less than half the per capita expense of the US.
    I have some experience with the Swiss system which is much like the new US design (mandatory private insurance). They have strong regulation of prices and services which keeps costs low and quality high.