Despite the fact America gained independence from the British more than 200 years ago, our two countries have plotted very similar cultural, social and political courses over this period. One area however, where there has been significant divergence has been in the delivery of population-wide healthcare coverage.
Americans are at best skeptical and often openly hostile to the concept of “socialized medicine;" as evidenced by the all too recent media storm around “death panels” and rationing of care. But is it all bad over on the other side of the Atlantic? Should the U.S. take a closer look and dare I say it, “cherry pick” some of the good things about centrally funded comprehensive healthcare delivery?
The fact that the United States is by far the most expensive healthcare system in the world is hardly news; however, exploring the differences between how the UK and U.S. go about delivering care raises some points that warrant further investigation. The first thing to remove from the debate is the funding mechanism; whether healthcare is funded purely from taxation or from a health insurance model is, in the most part, immaterial. Certainly this difference alone cannot possibly explain the fact that the US healthcare system consumes nearly 18 percent of GDP, whereas the UK figure is nearer 10 percent.
One major and striking difference between the two systems is the mechanism by which individuals access care. Excluding acute and life-threatening illnesses, the normal access point for medical care in the UK is via a primary care physician (usually called a general practitioner, or GP for short). The majority of the UK population is registered with a named primary care physician, with everything from the usual coughs and colds through to headaches, joint pains and skin rashes seen, at least initially, by the GP.
People in the UK do not have direct access to specialist physicians. With a few rare exceptions, the GPs act as “gatekeepers” to the more expensive secondary care services and investigations. “Aha!” I hear you say, “that’s rationing, and that is bad!” But is it really? If you look at the outcomes for major conditions between the U.S. and the UK there is very little difference; same cure rates, same 5-year life expectancies, there is really very little to choose between the two nations.
This kind of physician triage is only possible, however, because the UK has a comprehensive network of primary care physicians. This is not the case in the U.S. Why is this? Possibly because in the UK there is no financial penalty as a newly graduated physician to enter general practice; in fact many GPs earn more than their hospital-based specialist colleagues. However, this is not the case in the U.S. where specialization is seen by many as being the only route by which to recoup the large debts amassed during their medical school years. It certainly seems intuitive to explore incentivizing graduates to enter family practice, as it is clear that this is a more cost efficient way of managing the health needs of a population as a whole.
Another area that warrants further exploration is the redundant capacity evident in much of the U.S. healthcare system. Americans have become used to demanding their scan or investigation within a day or two, and in order to accommodate this expectation there needs to be a significant amount of slack within the system. Although some commentators would have you believe that you can wait half a lifetime for an MRI scan in the UK this is actually not the case. Granted, there was a time a decade or so ago when waiting lists were long and undoubtedly outcomes suffered because of this. But the fact of the matter is that in most cases whether you wait a day or a week for your investigation actually makes very little, if any, difference to your outcome.
Ultimately there are two ways to go about changing expectations in this area: either, like in the UK, you say there is no option but to wait, or you ensure there is a significant price differential between an immediate test and one that can be scheduled for a short period of time in the future. In many ways the U.S. healthcare system has an advantage in this respect, as consumers are aware of the costs associated with their investigations and treatment. The UK patient is blissfully ignorant of how much a scan, a course of antibiotics or a hospital visit with a specialist really costs.
With the global economic downturn unlikely to rectify itself in the near future there are some hard decisions ahead for both of our countries. With virtually no economic growth we cannot sustain the inexorable rises in healthcare delivery costs witnessed over the last two decades, no matter how the system is funded.
The British people will not accept further increases in taxes; similarly Americans and American employers cannot afford to pay any more than they currently do for health insurance. Part of the solution has to be around how the population access expensive healthcare resources and what their expectations regarding the timeliness of those interactions are. In addition, we as a physician body have to change the way we approach delivering healthcare to a population. It is no longer acceptable to sit in our offices and wait for people to turn up with health problems; we have to be proactive and manage the whole population we are responsible for, rather than just those who knock on our doors when sick.
Here lies the real challenge for the coming decade; we need to be engaged in reducing lifestyle and behavioral health risks before they manifest themselves as costly diseases. That’s where the “rubber hits the road” and we cannot dodge that responsibility any longer.
Peter Mills, MD, is an authority on driving behavioral change to improve individual and community well being. He is the founder of Glasslyn Health Solutions in London, UK.