Perspective
British Lessons on Health Care Reform
N Engl J Med 2009; 361:e21September 24, 2009
- Article
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.”
Has this investment significantly improved the quality of care? There have been massive improvements in waiting times for care and in general patient satisfaction with the NHS, as well as real improvements in outcomes (fewer deaths from cardiac causes and from cancer), but there has not been a clear correlation between the amount invested and hard health outcomes, and Britain's Audit Office has raised doubts about the link between productivity and salary increments.
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 community4; 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
In the United States, by contrast, primary care is an area of relative weakness that must be addressed if the current proposals for health care reform are to be sustainable. In the early days of the NHS, general practice in Britain was in a similar state of weakness. But with the establishment of the Royal College of General Practitioners in 1952, a unified approach could be taken to developing the discipline, which was accomplished through the professionalization of medical education and training, the embracing of undergraduate teaching, the recognition and description of the importance of the doctor–patient relationship as part of the therapeutic process, the development of a quality agenda for the management of chronic conditions, and the establishment of methods for building partnerships with patients. This approach has lent a validity and respectability to the discipline, which, along with the rewards of long-term relationships with patients, has made general practice a positive career choice for many young doctors.
A second key lesson might be learned from the role of NICE. This organization was initially established to end regional differences in access to medical care — or what has been called a “postal-code lottery of prescribing.” Because of localized decision making in the NHS, one patient might be granted access to an expensive procedure while another patient living in a neighboring region with a different administrative health authority might be denied access. Such differential treatment seemed, and was, arbitrary — driven by geography and inimical to the concept of a truly national health service. NICE was therefore established to provide a unifying national framework to offer guidance in public health, new health technologies, and clinical practice. Another mandate of the agency, which was to provide guidance on technology appraisal, has proved to be more controversial, since it has provided a means for the NHS to ensure “value for money” by using the evidence base to weigh the benefits and costs of any new drug or medical procedure.
It is generally accepted that the statistical methods and appraisal process established by NICE are logical and transparent and invite participation from clinical experts, industry, and patients. Most of the debate centers on the concept of cost per quality-adjusted life-year gained and on where the funding cutoff is set. For instance, is an extra month of life for a patient with cancer worth $1,000, $10,000, or $100,000? Admittedly, cancer survival is worse in Britain than in the United States, where there are far higher numbers of cancer specialists, better access to novel therapies, and more widespread informal cancer screening, but it is unclear which, if any, of these factors contributes the most to this cancer-survival gap.
The sorts of questions that NICE decides are at the heart of the debate over U.S. health care reform. Can we automatically fund any advance in health care, regardless of how marginal the benefit might be, or is it possible to introduce a transparent, rule-based, evidentiary form of health care rationing? At the moment, health care rationing in the United States is based on the exclusion of the poorest people, through a health care system that runs on perverse incentives for physicians and increasingly transforms their profession into a business that is driven by an unsustainable proportion of the nation's GDP. The NHS is far from perfect, but the best of socialized health care is not the evil being painted by some opponents of U.S. health care reform. Important and relevant lessons could and should be learned from it.
No potential conflict of interest relevant to this article was reported.
This article (10.1056/NEJMp0906618) was published on September 9, 2009, at NEJM.org.
Source Information
From the Department of Clinical Pharmacology, University of Oxford, Oxford, United Kingdom, and the Sidra Medical and Research Center, Doha, Qatar (D.J.K.); and the Division of Clinical and Population Sciences and Education, University of Dundee, Dundee, United Kingdom (M.S.).
- References
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
Full Text | Web of Science | Medline4
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
CrossRef | Web of Science | Medline
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