The US doesn’t have a National Health Service. Instead there are dozens of different models of healthcare provision, some much better than others and some perhaps better than ours. The US surgeon, public health expert, philosopher and writer Atul Gawande has been finding out which aspects of US healthcare provision we might benefit from emulating.
His articles, published in the last couple of months in the New Yorker and the New York Times have shown that high quality, low cost healthcare is possible in the same country that has some of the most extravagantly expensive, averagely effective healthcare in the world.
The Mayo Clinic in Northern Minnesota offers exemplary care at $8000 less per person each year than McAllen (its Medicare costs are in the lowest 15% of costs for the whole US) It does this by removing financial incentives from clinical decision making, by paying staff salaries or fixed fees instead of linking pay to procedures and by significantly improving the level of teamwork by facilitating communication and collaboration between all the professionals involved in patient care. Costs were reduced and there were less unnecessary investigations and less clinical errors. The Mayo clinic isn’t the only example he gives of affordable excellence, there are others, all non-profit hospitals with excellent levels of communication that offer care with higher quality care and lower costs than average American towns.
Gawande contrasts this with the US most expensive healthcare in McAllen, Texas. Here the extraordinarily high costs are due to doctor-owned, for-profit hospitals that have financial incentives to investigate, medicate and dissect as many patients as much as possible. As Bernard Shaw said in his preface to The Doctor’s Dilemma, “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.” He was speaking at a time before the link between cutting off legs and making a profit was broken by the NHS; in Shaw’s day private doctors to the wealthy indulged them with all kinds of nonsense to make sure they came back for more. According to the same logic nowadays private health advocates most frequently quote patient satisfaction rather than clinical outcomes as a measure of their success.1
What are we doing in the UK?
Far from following the example of the Mayo Clinic, we’re following the example of McAllen. Established by the Department of Health in 2003, NHS Foundation Trusts must be run as businesses and make an annual financial surplus. Payment by results forces providers to compete for patients making the link again between cutting off legs and making a profit. Financial competition for patients and a free market in providers makes it extremely difficult for hospital departments and GPs to communicate effectively and collaborate in the best interests of their patients because they’re forced all the time to consider who is getting paid to do what rather than what’s in the best interests of the patient.
How on earth did we get McAllen instead of Mayo?
In the UK, US prvatisation advocates such as Tony Blair’s advisor Simon Stevens, now CEO of US Health insurance giant United Health have been lobbying and advising the UK government about healthcare reform for the last 20 years. I won’t repeat the details because they have been thoroughly documented in the essential books, ‘The NHS after 60’ by John Lister and ‘Confuse and Conceal, the NHS and Independent Sector Treatment Centres’ by Colin Leys and Stewart Player. What these books reveal is the depth to which profit seeking US corporations have influenced healthcare reform in the UK. The new book by Leys and Player, The Plot against the NHS brings the details up to date (edited 14.4.2011)
Instead of fawning over the NHS and abusing the US system, we ought, like Atul Gawande, to carefully examine what factors lead to the most effective, equitable and efficient healthcare in the UK and we need to ask why our politicians are not standing up to the private health insurance lobby as Barack Obama is.
1No Turning Back, BMA news May 23rd 2009 p.15
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Excellent lecture by Jack Wennberg courtesy of the Kings Fund, December 2010:
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