British Lessons on Health Care Reform (New Eng Jour Med)

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British Lessons on Health Care Reform
David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B.

Amid widespread recognition that the U.S. health care system cannot continue its current upward cost spiral, forever widening the life-expectancy gap between rich and poor, Britain’s National Health Service (NHS) has made a cameo appearance as bogeyman in politically funded, shroud-waving TV ads. These spots warn citizens that if certain of President Barack Obama’s health care reforms are pushed through, the country will end up with a Third World, socialized health care system — much like the NHS, heaven forfend. 1

The per capita cost of health care in the United States is about twice that in other major industrialized countries. In 2008, health care consumed 17% of the country’s gross domestic product (GDP) — a share that is projected to increase even more quickly over the next decade. 2 An important component of the high cost base is the continuing expansion of medical services that depend on increasingly costly diagnostic tools, new drugs, and surgical procedures. This focus on high-cost technology is linked to the country’s high proportion of specialists, who tend to rely on the delivery of increasingly expensive and technically complex care to maintain their income. Salary differentials between specialists and primary care physicians in the United States are widely believed to contribute to the relative dearth of general practitioners in the country. 3 There are financial incentives for applying the latest innovations, since U.S. health insurers currently pay doctors, hospitals, and clinics most of what they charge for such services.

In Britain, which has taxation-based universal health coverage that provides free care at the point of delivery, the government determines how expenses are reimbursed, negotiates salaries and contracts with its 1.4 million NHS employees, and limits the availability of expensive technology through the National Institute for Health and Clinical Excellence (NICE). When the current government came to power in 1997, it recognized that health care spending was inappropriately low (Britain’s total expenditure on health was 6.6% of its GDP, as compared with 13.4% in the United States at that time). 1 In the intervening decade, Britain has made major investments in its health care system, raising the total expenditure to 8.4% of the GDP in 2007, as compared with 16% in the United States. These funds, which effectively doubled NHS spending, from $75 billion to $159 billion per year, have been used to build new hospitals, hire more nurses and doctors, provide an improved base for physicians’ salaries linked loosely to productivity, and enhance the research infrastructure in order to generate a stronger evidence base for clinical care guidelines. The prevailing political philosophy was that introducing competition and patient choice into this monolithic market would be the best means of raising standards — an intellectually appealing concept that was diluted somewhat by the British public’s apathy toward becoming health consumers and perhaps by the government’s failure to equip people with the necessary information to “shop for health.”

So what can the United States learn from the NHS? The jewel in the NHS crown is the strength of its primary care and its general practitioners. These highly trained physicians contribute to Britain’s health by focusing on the health of the whole person, rather than on a single organ; emphasizing prevention and health screening, which should reduce the life-expectancy gap between rich and poor, currently about 13 years in Britain; acting as gatekeepers, who control costs by referring only patients who truly require a specialist’s opinion, since 86% of medical needs can be managed in the community 4; and providing continuity and coordination of care and being patients’ constant companions in the domain of health care. As a result, NHS patients have great trust in their own doctors, which allows general practitioners to absorb diagnostic risk and so reduce hospitalizations, excessive investigations, and inappropriate prescribing, as well as to enhance anticipatory care and improve patient satisfaction and health outcomes. 5

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References

1.McGreal C. US health lobby: reform could make us as bad as the NHS. May 13, 2009. (Accessed August 27, 2009, at http://www.guardian.co.uk/world/2009/may/13/advertising-campaign-nhs-us-healthcare-reforms.)

2.OECD Health Data 2009 — comparing health statistics across OECD countries. Paris: Organisation for Economic Co-operation and Development. (Accessed August 27, 2009, at http://www.oecd.org/document/54/0,3343,en_2649_201185_43220022_1_1_1_1,00.html.)

3.Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med 2009;360:2693-2696.

4.Pereira-Gray D. 12 Facts about general practice in the UK. RCGP Curriculum Information, 2002. (Accessed August 27, 2009, at http://www.gpcurriculum.co.uk/rcgp/12_facts.htm.)

5.Haslam D. “Schools and hospitals” for “education and health.” BMJ 2003;326:234-235.

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http://healthcarereform.nejm.org/?p=1702&query=TOC

© 2009 Massachusetts Medical Society

[AdHocSolver]

1. More primary care physicians means illness prevention, lower costs, better patient advocacy.

K and R.

A lot of tests and procedures are done for no other reason than to make money. I learned that a long time ago having worked in a hospital, and for a company that supplied medical equipment to doctors and hospitals.