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British Lessons On Health Care Reform



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  • 1. The NEW ENGLA ND JOURNAL of MEDICINE Perspective British Lessons on Health Care Reform David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B. A mid widespread recognition that the U.S. health care system cannot continue its current upward cost spiral, forever widening the life-expectancy In Britain, which has taxation- based universal health coverage that provides free care at the point of delivery, the government gap between rich and poor, Britain’s National Health determines how expenses are re- imbursed, negotiates salaries and Service (NHS) has made a cameo services that depend on increas- contracts with its 1.4 million appearance as bogeyman in politi- ingly costly diagnostic tools, new NHS employees, and limits the cally funded, shroud-waving TV drugs, and surgical procedures. availability of expensive technol- ads. These spots warn citizens that This focus on high-cost technol- ogy through the National Insti- if certain of President Barack ogy is linked to the country’s high tute for Health and Clinical Ex- Obama’s health care reforms are proportion of specialists, who tend cellence (NICE). When the current pushed through, the country will to rely on the delivery of increas- government came to power in end up with a Third World, social- ingly expensive and technically 1997, it recognized that health ized health care system — much complex care to maintain their care spending was inappropriate- like the NHS, heaven forfend.1 income. Salary differentials be- ly low (Britain’s total expendi- The per capita cost of health tween specialists and primary ture on health was 6.6% of its care in the United States is about care physicians in the United GDP, as compared with 13.4% in twice that in other major industri- States are widely believed to con- the United States at that time).1 alized countries. In 2008, health tribute to the relative dearth of In the intervening decade, Britain care consumed 17% of the coun- general practitioners in the coun- has made major investments in try’s gross domestic product (GDP) try.3 There are financial incen- its health care system, raising the — a share that is projected to in- tives for applying the latest inno- total expenditure to 8.4% of the crease even more quickly over the vations, since U.S. health insurers GDP in 2007, as compared with next decade.2 An important com- currently pay doctors, hospitals, 16% in the United States. These ponent of the high cost base is the and clinics most of what they funds, which effectively doubled continuing expansion of medical charge for such services. NHS spending, from $75 billion 10.1056/nejmp0906618 e21(1) Downloaded from on December 23, 2009 . For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.
  • 2. P ERS P E C T IV E British Lessons on Health Care Reform to $159 billion per year, have health by focusing on the health importance of the doctor–patient been used to build new hospi- of the whole person, rather than relationship as part of the thera- tals, hire more nurses and doc- on a single organ; emphasizing peutic process, the development tors, provide an improved base for prevention and health screening, of a quality agenda for the man- physicians’ salaries linked loose- which should reduce the life- agement of chronic conditions, ly to productivity, and enhance the expectancy gap between rich and and the establishment of methods research infrastructure in order to poor, currently about 13 years in for building partnerships with generate a stronger evidence base Britain; acting as gatekeepers, who patients. This approach has lent for clinical care guidelines. The control costs by referring only a validity and respectability to the prevailing political philosophy was patients who truly require a spe- discipline, which, along with the that introducing competition and cialist’s opinion, since 86% of rewards of long-term relationships patient choice into this monolith- medical needs can be managed with patients, has made general ic market would be the best means in the community4; and providing practice a positive career choice of raising standards — an intel- continuity and coordination of for many young doctors. lectually appealing concept that care and being patients’ constant A second key lesson might be learned from the role of NICE. In Britain, the government determines how This organization was initially es- tablished to end regional differ- expenses are reimbursed, negotiates salaries and ences in access to medical care — or what has been called a contracts with its 1.4 million NHS employees, and “postal-code lottery of prescrib- limits the availability of expensive technology. ing.” Because of localized deci- sion making in the NHS, one pa- was diluted somewhat by the companions in the domain of tient might be granted access to British public’s apathy toward health care. As a result, NHS pa- an expensive procedure while an- becoming health consumers and tients have great trust in their other patient living in a neigh- perhaps by the government’s fail- own doctors, which allows gen- boring region with a different ure to equip people with the nec- eral practitioners to absorb diag- administrative health authority essary information to “shop for nostic risk and so reduce hospital- might be denied access. Such dif- health.” izations, excessive investigations, ferential treatment seemed, and Has this investment signifi- and inappropriate prescribing, as was, arbitrary — driven by geog- cantly improved the quality of well as to enhance anticipatory raphy and inimical to the concept care? There have been massive care and improve patient satis- of a truly national health service. improvements in waiting times faction and health outcomes.5 NICE was therefore established to for care and in general patient In the United States, by con- provide a unifying national frame- satisfaction with the NHS, as trast, primary care is an area of work to offer guidance in public well as real improvements in out- relative weakness that must be ad- health, new health technologies, comes (fewer deaths from cardiac dressed if the current proposals and clinical practice. Another causes and from cancer), but for health care reform are to be mandate of the agency, which was there has not been a clear corre- sustainable. In the early days of to provide guidance on technol- lation between the amount in- the NHS, general practice in Brit- ogy appraisal, has proved to be vested and hard health outcomes, ain was in a similar state of weak- more controversial, since it has and Britain’s Audit Office has ness. But with the establishment provided a means for the NHS raised doubts about the link be- of the Royal College of General to ensure “value for money” by tween productivity and salary in- Practitioners in 1952, a unified using the evidence base to weigh crements. approach could be taken to de- the benefits and costs of any new So what can the United States veloping the discipline, which was drug or medical procedure. learn from the NHS? The jewel in accomplished through the pro- It is generally accepted that the the NHS crown is the strength of fessionalization of medical edu- statistical methods and appraisal its primary care and its general cation and training, the embrac- process established by NICE are practitioners. These highly trained ing of undergraduate teaching, the logical and transparent and in- physicians contribute to Britain’s recognition and description of the vite participation from clinical ex- e21(2) 10.1056/nejmp0906618 Downloaded from on December 23, 2009 . For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.
  • 3. PE R S PE C T IV E British Lessons on Health Care Reform perts, industry, and patients. Most less of how marginal the benefit From the Department of Clinical Pharma- cology, University of Oxford, Oxford, United of the debate centers on the con- might be, or is it possible to in- Kingdom, and the Sidra Medical and Re- cept of cost per quality-adjusted troduce a transparent, rule-based, search Center, Doha, Qatar (D.J.K.); and the life-year gained and on where the evidentiary form of health care Division of Clinical and Population Sciences and Education, University of Dundee, funding cutoff is set. For instance, rationing? At the moment, health Dundee, United Kingdom (M.S.). is an extra month of life for a care rationing in the United States patient with cancer worth $1,000, is based on the exclusion of the This article (10.1056/NEJMp0906618) was published on September 9, 2009, at NEJM. $10,000, or $100,000? Admitted- poorest people, through a health org. The jewel in the NHS crown is the strength of 1. McGreal C. US health lobby: reform could make us as bad as the NHS. May 13, 2009. (Accessed August 27, 2009, at http:// its primary care and its general practitioners. advertising-campaign-nhs-us-healthcare- reforms.) ly, cancer survival is worse in care system that runs on per- 2. OECD Health Data 2009 — comparing Britain than in the United States, verse incentives for physicians health statistics across OECD countries. where there are far higher num- and increasingly transforms their Paris: Organisation for Economic Co-opera- tion and Development. (Accessed August 27, bers of cancer specialists, better profession into a business that 2009, at access to novel therapies, and is driven by an unsustainable pro- 0,3343,en_2649_201185_43220022_1_1_1_ more widespread informal cancer portion of the nation’s GDP. The 1,00.html.) 3. Bodenheimer T, Grumbach K, Berenson screening, but it is unclear which, NHS is far from perfect, but the RA. A lifeline for primary care. N Engl J Med if any, of these factors contrib- best of socialized health care is 2009;360:2693-6. utes the most to this cancer-sur- not the evil being painted by 4. Pereira-Gray D. 12 Facts about general practice in the UK. RCGP Curriculum Infor- vival gap. some opponents of U.S. health mation, 2002. (Accessed August 27, 2009, The sorts of questions that care reform. Important and rele- at NICE decides are at the heart of vant lessons could and should be facts.htm.) 5. Haslam D. “Schools and hospitals” for the debate over U.S. health care learned from it. “education and health.” BMJ 2003;326: reform. Can we automatically fund No potential conflict of interest relevant 234-5. any advance in health care, regard- to this article was reported. Copyright © 2009 Massachusetts Medical Society. 10.1056/nejmp0906618 e21(3) Downloaded from on December 23, 2009 . For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.