A new blog by Dr. Ida Hellander, PNHP policy director

Post 1

Dr. Clare Gerada, president of the Royal College of General Practitioners, visited Chicago recently on a study tour to see how a market-based system works for society’s most vulnerable first hand. I was fortunate to be able to accompany her on several of her stops.

Dr. Clare Gerada

In her practice in London, Dr. Gerada is able to diagnose and treat patients without regard to their income. In Chicago, she observed patients grateful to be able to get a tooth filled or a school health exam at free clinic sponsored by Remote Area Medical; visited federally qualified community health centers struggling to stay afloat – at least partly by limiting the percentage of uninsured patients they see; and toured the county hospital where dozens of patients wait on gurneys in the hallway for beds and a budget deficit threatens further cutbacks. Meanwhile the private hospital across the street is expanding luxuriously with a comfortable surplus.

U.S. insurers in England: Going for the gold

The British system of socialized medicine, the National Health Service, has been under attack for over a decade. Under the guise of promoting choice, cost-control and competition, one of the most efficient health systems in the world is being broken up, privatized, and pushed in the direction of U.S.-style inefficiency.

The latest proposal, the Health and Social Care bill, would divide the NHS into 300 GP-led “clinical commissioning groups” (CCGs) responsible for “purchasing” NHS care for all their patients, including medications. In effect, it would set up 300 different managed care insurance companies, with the massive increase in bureaucracy that entails, higher prices, and rising inequality. Indeed, U.S. insurers like United Healthcare and CIGNA are already jockeying for lucrative management consulting contracts, while pharmaceutical firms are no doubt celebrating in their board rooms.

Even more worrisome is the bill’s expansion of the private delivery of care, including by for-profit, investor-owned delivery systems, by lifting the cap on using NHS funds for “independent treatment centers” and other private providers in competition with the NHS. Each commissioning group would have the ability to decide who provides care along with what is and what isn’t NHS-funded care, opening the door to user fees as well as privatization.

“Increasingly there will be enormous variation in who gets access to care, on what basis and what is paid for and what is free at the point of delivery,” according to Dr. Allyson Pollock. A recent study by Dr. Pollock published in the British Medical Journal on the outcome of an earlier privatization scheme, the private-finance initiative (leasing back hospitals built for the NHS with funding from private investors), found that it raised costs several fold over the duration of the contracts.

Canadian economist Robert Evans calls the process of privatization, which ultimately redistributes health services from the poor to the affluent and tax dollars to investors, “going for the gold.” Although the latest proposal to privatize the NHS is on hold for a few months, it has already passed the British House of Commons.

Four lessons from Dr. Gerada

1. “The NHS works.” As the difference between services for the poor in Chicago versus England sank in, Dr. Gerada noted that the NHS works because of its equity. In addition to her own practice and the practices she knows nationwide through her work with the Royal College, she related two recent personal experiences. In the first, she found herself in the emergency room with a broken ankle a few doors down from a housekeeper she knew, also injured with a broken ankle. She asked about the housekeeper’s care, and was pleased but not surprised to find out the housekeeper had received identical care to her own. In the second, she had a dream in which she worried about the health and cost of caring for two relatives with serious chronic disease. When she woke up, she was greatly relieved that, because of the NHS, she didn’t have to worry in real life about paying for their medical care. “The NHS is not broken” she told me, noting that the British Medical Association had wholeheartedly rejected the government’s proposal. The BMA started enlisting public support for a campaign to stop the commercialization of the NHS a few years ago. Incidentally, there’s even a rap song against privatization, taking aim at Health Secretary Andrew Langsley.

2. Privatization raises costs and is destabilizing. In addition to the private-finance initiative that raised hospital costs dramatically, nursing homes were privatized by an American-owned firm, Southern Cross. The firm is now in bankruptcy, and the fate of the patients and the homes is unclear.

3. Pharma’s gain is the public’s loss. Making every GP-led group responsible for developing its own formulary and negotiating drug prices will raise costs and lower quality. Pharma is seeking to undermine the cutting-edge work of the National Institute for Clinical Evaluation (NICE) and the purchasing power of the NHS. Drugs are much cheaper in England than in the U.S., and thanks to NICE, the British don’t pay for a few expensive drugs that only extend life a few weeks. This could all change for the worse.

4. Finally, the NHS uses their (better) data to improve quality. Dr. Gerada noted that the NHS is starting an initiative to review anti-psychotic use in patients over age 80 to reduce falls. It will take a day or two for the NHS to produce the list of affected patients so GPs can evaluate whether they need to be on an anti-psychotic, she said. No similar ability to retrieve population-wide data to improve quality exists in the U.S. It can’t be done. Similarly, a study using a British registry of patients with a particular brand of all-metal artificial hips recently found that nearly one-third of the hips were failing in the patients who had been followed the longest. Although artificial hips are used more frequently in the U.S. than England, there is no equivalent registry here to study outcomes. While there is some awareness abroad that the U.S. has a two-tiered system, with poor access and a high burden of untreated illness among the poor, Dr. Gerada found it surprising that U.S. has so little quality-improvement infrastructure. The myth in the U.K. is that the U.S. is very advanced in terms of its quality systems and that physicians have all the data they need at their fingertips. In fact, our fragmented payment system leads to lower quality care for everyone. The most useful data sets for health service researchers in the U.S. are generated by our single-payer insurance program for the elderly, Medicare, and our single- payer health service for veterans, the Veterans Health Administration.

As all who met her in Chicago can attest, Dr. Gerada is an energetic and passionate family physician. She showed great concern for the health of her patients and the ability of her colleagues in the NHS and the Royal College to provide quality medical care to all without financial barriers to care. Protecting and improving the NHS is clearly her top priority.