It’s the GPs, Stupid. Care Coordination in Britain’s NHS.

The Bowler Hats Come Marching Home

A recent report from the Commonwealth Fund places the US last amongst developing nations in healthcare. For self-loathing Americans, Christmas couldn’t have come earlier. Raptures of ecstasy were oozing from pores of self-satisfying righteous indignation.

Anyway that, and the shakiness of the metrics for another time.

For now I will focus on one of the conclusions. In analyzing the Britain’s high score on the management of chronic conditions the authors attributed this care coordination to the widespread adoption of health information technology.

That’s like someone saying Chinese food is tasty because chopsticks are widely used.

Sigh! Like quants so fastidious about decimal points they’ve missed the overall point.

Where do I begin?

I’ll start with Mesozoic era, i.e. before health IT was thrust upon Britain’s general practitioners (GPs). Then you had GPs and specialists. In Britain GPs are not optional ornaments for the mantelpiece that you pick up from Ikea when you feel like.

No, they are rather compulsory. Everyone needs to be registered with a GP. Ok, you don’t get fined if you don’t have one, but if you want a referral to a cardiologist you need to see your GP which means you must have one to see in the first place.

Read my lips: no GP, no cardiologist.

If your cardiologist thinks there is nothing wrong with your heart and your problems are supratentorial for which you need to see a shrink, then he must write a letter to your GP asking that he might consider referring you to the psychiatrist. The specialist can’t send you directly to another specialist, bypassing your GP.

Of course, you can see a psychiatrist privately in Harley Street, London or the south of Spain (which is where the Daily Mail readers, the Moaning Myrtles from the middle class, head for private care).

The result is that GPs know their patients. They know the genuinely ill. They know the pesky college-educated ignoramuses who, adept at web searching “dizziness”, end up with a diagnosis of pheochromocytoma of the bladder from Dr. Google.

“Doctor, sometimes I get dizzy when I urinate. I think I have this big sounding cancer of the bladder”.

Congratulations! We know you can google.

Let me state this differently. Every patient has one doctor who knows everything of medical relevance about them (nearly).

How were these Paleolithic GPs communicating before electronic medical records?

Pigeons? Telegraph? Morse code? Smoke from chimneys? No, it was a rather quaint thing called a referral letter.

You know the ones that start off with:

“Dear Dr. Singh,

Many thanks for seeing this delightful 68 year old lady of Indian origin who is somewhat active for her age, but has recent deterioration in exercise tolerance. I have reduced the dose of her daily atenolol. She is not anemic.”

Then Dr. Singh would reply:

“Dear Dr. Smith,

Thank you for referring Mrs. Patel, a delightful 68 year old lady who was accompanied by her concerned daughter-in-law, a Cambridge-educated barrister. The reduction in atenolol has restored her to baseline physical activity. I was happy to report to her that the electrocardiogram and chest X-ray you so kindly arranged were normal. No further investigations are necessary but I have requested an echocardiogram, to reassure her Cambridge-educated daughter-in-law.


Dr. Maninder Singh, FRCP (Manny)

PS: I haven’t seen you on the golf course recently.”

Dr. Smith is forewarned of Mrs. Patel’s aggressive daughter-in-law. Mrs. Patel remains delightful, and well managed. More importantly, both providers are in the know.

There’s a name for this. It’s called “communication.”

It doesn’t require schools of clever programmers, reams of codes, scores of entrepreneurs and mountains of subsidies from big government. It arises partly because of culture and partly from necessity.

It arises when GPs must be sovereign in their knowledge about the patient. When GPs are the masters of primary care and the drivers of secondary care. When GPs are care givers, care coordinators and the care chroniclers. That’s a lot of responsibility.

Is such a system restrictive?

Of course it is. Imagine you have a headache. You see a picture of this clever neurologist working in a center of excellence, with Alec Baldwin-style gelled hair, and shining teeth, on a billboard on I-95. How unconstitutional must it be to have to go through a primary care physician (PCP) and not exercise your constitutional right to see a specialist directly?

Britain doesn’t have these problems. Partly because they don’t have billboards of smiling neurologists with their beautiful families on freeways. Partly because they don’t have to worry about the interstate commerce clause and swinging Justice Kennedy rescuing common sense from unfettered logic. But mostly, I dare say, it’s because they know that with universal healthcare comes compromise.

Some people here balk at the “c” word. Even more than they balk at the “u” word. Particularly if the “u” word implies the “c” word.

Britain’s GPs are battle-hardened. They often deal with soaring demands that exceed the resources of the healthcare system.

My friend, a GP, had this conversation with a patient.

Patient: “I need a heart CAT scan.”

GP: “Perhaps. But first you must tell me what’s wrong with you.”

Patient: “I have chest pain.”

GP: “Can you point to where you feel the pain?”

Patient: “I just told you! It’s in my chest. And I need a CAT scan.”

GP: “Yes, but you must still point to where it hurts.”

Patient: “You are a lousy doctor. I will write to the Daily Mail. If I die from heart attack it will be on your conscience.”

GP: “My receptionist will help you fill the complaints. We also have the name of some GPs in the neighborhood, should you choose to change your GP.”

Patient stomped off. Patient complained. My friend wrote an apology letter that expressed “deep regret” and gratitude for “timely call to introspection about the greater values in society.” Thanks to health IT he has a cache of standardized letters (computers do have some use) which express varying degrees of regret. For this interaction he used the “mild regret” macro.

Nothing came of the complaint. He had documented the conversation.

Do American PCPs have the gall to ignore a patient’s demand for medical imaging? What, with all the Press Ganey scores, defunct quality metrics and consumer-centric stuff? What, with another PCP with shining teeth, a beautiful family and gelled hair around the corner ready to steal the consumer? What, with all the lawyers with the evangelical certitude of Jerry Falwell, waiting to pounce on that statistically-inevitable bad outcome?

My friend is not terribly concerned about Britain’s scarce resources or population health. Or that Orwellian term “resource stewardship.”

“If I acquiesce to her demand for CAT scan I’ll have to say yes to everyone. And we’re not like the states. We don’t have CAT scans in shopping centers. We have to triage and think about clinical necessity.” My friend reflects seriously after I high five him repeatedly for his story.

Britain’s GPs, indeed all physicians and patients, are constrained in their utilization BY the constrained resources of the system. US policy makers want US physicians to constrain their utilization TO constrain the presently abundant resources and without compromising anything, least of all consumer satisfaction. That’s a big difference. It’s the difference between passive diffusion and active transport.

I digress. But not that far. For care coordination health IT is neither necessary nor sufficient. You need a provider charged with overall responsibility for the patient, who can be bypassed by neither the patient nor the specialist. The provider will have responsibility. And therefore power. Including the power to ignore the patient’s demands without repercussions. Otherwise the system will collapse.

In Britain that provider is the GP. In USA I see no candidate. This is not because the PCPs are not up to the task. They are more than capable. It’s because the system will punish them for trying. It’s because the policy makers are not willing to put their Press Ganey scores where their mouths are. It’s because healthcare reform seeks a fairy tale NHS, ceteris paribus.

The report places Britain at number 1. Yet I doubt that many Americans, even the self-loathing ones, the self-proclaimed NHS-philes, could abide Britain’s NHS for a day. Not when it interferes with that sacred cow called “choice.”

The report is prescriptively useless for all, particularly fossil fuel billionaire Sheikh Abdullah from Bahrain seeking treatment for cancer, who is still likely to visit MD Anderson for treatment rather than a district general hospital in Britain’s NHS where they still write quaint referral letters.

Yes, but high intensity of medical treatment doesn’t improve national outcomes, a clever health economist will solemnly warn the Sheikh. Choose Switzerland. Choose Norway. But stay away from the US.

Yes, but what do I care about populations, the sheikh will rejoin. It is I with the cancer, not the Republic of Bahrain.

Such is healthcare, and those that measure it, and those that use it. A mind-boggling paradox.



13 replies »

  1. Dear Dr. Jha

    A very well written blog. Your opinions are based on you having worked in both systems and here are mine based on having lived in both systems. When I (a then 22 yr old) visited a GP in the NHS system with severe abdominal pain that began after I ate – I was diagnosed with maybe missing my family ( as I was recently married and GP knew my mom-in-law as a long time patient). The diagnosis did not help and needless to say the pain continued and I refrained from going back to the doctor to avoid further humiliation. Fast forward I move to the USA where after enduring the pain for over a year and a half now I am doubled up on the couch at 4 am. I visit the ER where the residents search for the Mickey Mouse in my stomach, the surgeon diagnoses me with gall stones and the radiologists confirm that infection was spreading and that the number of stones make gall bladder removal essential.

    I am healthy today and it isn’t owing to the GP familiarity but rather due to assessing my case free of the personal knowledge bias. To sum it up it is not essential for a doctor to know his patients for a very long time – rather it is important that a doctor has the patients records available in front of him during treatment and that the doctor has a system available that warns him should he be making any errors in the treatment.

    Health IT is the way to go for a better healthcare environment.

  2. I wonder if a little pilot with local pharmacists might help -not contractor to contractor, but professional to professional. Ease of communication and hand-off of patients for particular issues might be usefull. The more mundane review work could be triaged. Actual ways of working could be agreed between individual professionals, on a colleague to colleague basis,,akin to the way GPs already work with nurses, allied health professionals or consultants. Historical diagnosed LTC patients would be ideal. But transfer of information in a straightforward and easy way would make all this easier.

  3. According to British GP website PULSE, some see 84 patients per day:

    “At the moment, GP workload is out of control, while care is becoming more and more complex. GPs feel overwhelmed.
    For the first time in 25 years, my surgeries have begun to run late consistently and, as Pulse recently reported, GPs are beginning to report seeing as many as 84 patients in one day.”


  4. Believe it or not, despite my tone in the article, I am not making value judgments about healthcare systems. To each their own.

    Each system has its trade off.

    I was merely responding to the bit about care coordination.

    I believe a patient-centered system funded by third party payers which has an element of real equity will be more expensive than the system you have now.

    I’m not suggesting that such a system is not desirable. Just that it will cost.

  5. BAEber, the NHS is free (with taxes). Health care anywhere is a scarce resource and should not be squandered, even by patients. If you want no wait PCPs then be prepared to pay for it. If it’s an emergency go to the ER.

  6. Where is the patient in this discussion? Where is the idea of empowering the patient or having the patient be an active participant in his / her care? Not to mention not having to wait for a referral because it takes three weeks to get into see the PCP. I don’t agree with this argument at all. It’s not all about the GPs. It’s all about the people, i.e., the patients and THEIR health.

  7. Granpappy, are you saying the NHS is more efficient than the insurance based system here?

  8. It’s much quicker to dictate a good referral letter than to obtain one pre-auth from a for-profit insurer for a generic drug. Which would you prefer your doc spend their time on?

  9. It was delivered by horse and carriage. All letters had to be written in cursive without grammatical errors. Occasionally letters were put in a bottle and we hoped it would get to the right person.

    How do you think Robinson Crusoe was rescued? It was his GP.

  10. Was the referral letter written by quill, fountain pen, ball point pen, typewriter or MS Word? On parchment or commercial paper? Did the GP write it while the patient waited so that the letter could be hand delivered? How many patients can their GPs see in an hour AND write referral letters?

  11. Yes, and Yes again. The system works. it should not be a closed shop, I am a pharmacist and both patients panda GPs appreciate my place in their team. But I am more than happy working with the role that is GP.

  12. I have long believed that the cultural determinants of health are as important as the systemic. It’s politically incorrect to talk about culture when you compare systems, which is a pity …