Saturday, July 6, 2013

Will the NHS Survive in England?

Can England’s NHS Survive? Mixed Reviews and Reactions
Some critics have suggested the NHS faces a crisis that only be resolved by altering the fundamental principles of which  it was founded – provision of funding from general taxation, with care being free at the point of care.
Nicholas Butler, MD, Department of Health Services Research and Policy, London School of Halth Servics Rsearch and Policy, London School of Hygiene and Tropical Medicine,  New England Journal of Medicine,  July 4, 2013
It sounds odd, doesn’t it?  Questioning whether the NHS, the U.K.s wildly ropular 65 year old universal health program will survive.  It’s a little like questioning whether Medicare, also wildly popular, will survive.
That’s why I found three articles in the July 4 New England Journal of Medicine, so fascinating.
·         In the first, Nicholas Black, MD, asks how England can possibly cope with public austerity with no growth in NHS expenditures and administrative reorganization.  It is trying to do so by: 1)handing over NHS administration from nonclinical managers to general practitioners; 2) reducing staff pay, while increasing productivity; 3) coping with a lack of managerial capacity, while training GPs to feel comfortable with rationing care and reducing funds to their local hospitals. It’s a tough trick, and it isn’t going well.  Yet Dr. Black is optimistic because 1) “enterprising” clinicians, managers, and politicians are learning to work together; 2) the public remains enthusiastic over the NHS;  3) innovation is underway by bringing health care and social services under one budget.

·         The second article, “NICE: Moving Onward” is by Micahel Rawlins, MD, chairman of NICE from 1999-2013.   NICE stands for the National Institute for Clinical Excellence.  Rawlins is a NICE enthusiast, who believes NICE helps assure care that meets the highest possible standards. It does this through the collaborative efforts of citizens,  doctors, policy makers, and managers, and other health professionals working together to establish guidance programs, setting performance standards backed by metrics, and offering information services based on the latest evidence available.   Rawlins is particularly sanguine over the intergration of health care and social services under one budget.   Rawlins is pessimistic that the U.S. has the “political will” to set the priorities to make universal health care possible in the U.S.

·         The third article “From Imaging Gatekeeper to Service-Provider: A Transatlantic Journey,”is by Saurabh Jha, MB, MS, an English surgeon who came to the U.S. for a residency in diagnositic radiology.  He expresses amazement that U.s. radiologists perform imaging studies without challenging or denying clinicians who ordered the imaging.  In the U.K, radiologist are called “Dr.No,” because, more often not, they deny request for imaging for lack of clinical evidence.  He says U.S radiologists have no sense of limited resources and opportunity costs. The biggest obstacle to imaging overuse, he asserts, is the “service provision mindset,” i.e radiologists don’t want to displease referring physicians for fear they might refer elsewhere.   The solution, says Dr. JHa, is for radiologists to serve as imaging gatekeepers by “moving to the center” to teach clinicians when and when not to order. Otherwise, he maintains outside forces will cause the decline of imaging. Ja concludes, “Radiologists must decide whether to greet the ebb of imaging passively or by stepping forward to captain and manage a rational decline.”

My reaction to these articles?   The United States is not England.  We have a different culture.  We do not share the same stoicism towards disease.  We believe in our medical machines.   We  expect access to the best in technology.  We do not shre the same reverence for central planning or government.  We expect our doctors to cooperate, not challenge each other.  Our reimbursement incentives differ.  We have different legal systems with different incentives and disincentives.  We do not have the  same blind belief in the value of universal coverage as a common good for everyone.

Tweet:   Can the NHS survive in England? Can Obamacare survive in America?  Will the two nations adopt similar survival tactics?  I think not.

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