THCB

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.

References:
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.

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MGRey Joseph TaojoBarry CarolHMathewson, MD, www.hubslist.orgnate Recent comment authors
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nate
Guest
nate

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?

MG
Guest
MG

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,… Read more »

Rey Joseph Taojo
Guest

I do agree that a country should always be open to the ideas of other countries which gives a healthier population.

nate
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nate

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… Read more »

Peter
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Peter

“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.

nate
Guest
nate

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.

Peter
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Peter

“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.

Barry Carol
Guest
Barry Carol

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… Read more »

nate
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nate

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.

Peter
Guest
Peter

“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.

HMathewson, MD, www.hubslist.org
Guest

See Gawande’s latest New Yorker article, “Hot Spotters”, on how focussing cost reduction measures on the VERY high utilizers not only makes sense but actually works and is acceptable to the patients.

nate
Guest
nate

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.

Peter
Guest
Peter

“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… Read more »

nate
Guest
nate

“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… Read more »

Margalit Gur-Arie
Guest

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.