Summer in London: First Impressions

First of all, let’s get the important stuff out of the way. Mom, I’m fine. Thanks for your concern. Really.

I’ve now been in London for about 6 weeks on my sabbatical. The recent riots here are all folks are talking about and the trauma is real. One wonders whether the inevitability of budget cuts, high unemployment, increased polarization and pent-up anger—on both sides of The Pond—will mean that London-style violence will soon be coming to a theater near you. I hope not, but the events around England this week illustrate how fragile this thing called civilization is.

Still, I’ve been safe, lucky to be insulated in my lovely, upscale neighborhood of South Kensington. Even when I’ve gone afield, things seem pretty normal—the Tube is bustling, hot and sweaty, Regent Street is abuzz with shoppers. It’s all a little surreal.

In this dispatch, I’ll talk a bit about the modern sabbatical and then offer a few initial impressions of medical life in the U.K. The differences are fascinating, and—as I hoped—illuminate and enrich my own thinking about the U.S. healthcare system. Here goes:

Sabbaticals are wonderful things, although the disconnecting part is far harder than it used to be. It’s this damn box, you see. In the old days, you said goodbye, packed your bags, got on a plane, and off you went. Now, 95 percent of your interactions and information comes in and out through this electronic box, which you can no longer be without. Which means that the modern sabbatical-er needs to be quite intentional about disconnecting from work, lest all you’ve done is move your office 6,000 miles. For me, this remains a work-in-progress.

A parallel issue relates to where you get your news and entertainment. In the old days, you had to pick up the local paper and watch the BBC. Now, I still read my NY Times (online), watch the Daily Show (online), and I’m just starting season 3 of The Wire (iTunes). But I’m doing my best to walk everywhere, pick up one of the local papers every few days, check out the “Beeb” from time to time, and just take it all in.

It’s often the little differences that are the most striking. Our flat’s kitchen has “Washing Up Liquid” by the sink, and there is “Soured Cream” in the fridge. The newspaper is chock full of wonders. A businessman caught in a scandal was placed on “gardening leave.” A politician who criticized another was said to have “rubbished” the person. Some Murdoch-related gnome having a tough day confessed to needing a couple of “medicinal pints.” Great stuff.

Getting down to business, I’m beginning to get a handle on how the healthcare world really works here. I feel like those detectives on The Wire, with their corkboard filled with pictures of suspects, names of organizations, and tentative connections. Much of what they do is gather data and draw conclusions only after they have corroborating evidence from multiple sources. When I talk to someone here, I might hear something interesting but strange, and I tuck it away. But then I hear another person say something similar, and ultimately I feel like I’m homing in on the truth. Here are a few of the most striking things I’ve learned so far:

After musing about the glories of socialism after my recent trip to Norway, my time in the U.K. is bringing me back to earth, illustrating that too much central control of the healthcare system carries risks as well as benefits. A few examples:

First, the U.K. government took a heavy-hand in trying to implement information technology in the National Health Service (NHS) hospitals. That sounds OK at first blush, and our experience with the VA’s top-down IT implementation might have led me to predict success. But in the U.K., they totally bollixed the thing up [click here for a pdf of a fascinating and damning Parliamentary report on the sorry tale]. Front-line staff whose computers were dysfunctional had to struggle through several bureaucratic layers to get them fixed. Screens froze with metronomic regularity. Clinician training and buy-in was neglected. Interoperability was virtually nil. The result was shocking: after an investment by the NHS of more than $20 billion (a fair chunk of it pocketed by U.S. IT vendors), the state of IT in U.K. hospitals is well behind that of most reasonably sized hospitals in the States (and that’s not a very high bar). This leaves me more convinced than ever that the U.S. approach, combining federal subsidies with aggressive but achievable standards while not trying to manage the entire process from Washington, is the right one. Healthcare IT is an area in which the government needs to set ground rules and provide some dollars to grease the wheels, and then pretty much stay out of the way.

Similarly, the U.K.’s approach to patient safety and quality is much more top down and regulatory-driven than we’re used to, and I see less front-line provider engagement because of this. I’ll say much more about this in my next post, but the differences are plain to see.

That said, the government has exerted its control quite wisely in several areas. Of course, the NHS guarantees healthcare to everyone, which is its main benefit, and it’s a doozy. But there are others.

First, they do real manpower planning here, as they do virtually everywhere other than the U.S. If they need more geriatricians but fewer cardiologists or dermatologists, they adjust the training positions and the jobs to make it so. And—I hope you’re sitting down—all physicians, from the general practitioner to the neurosurgeon, make approximately the same amount of money (there are slight differences that emerge from the private insurance work that many physicians do, but the compensation gap is nowhere near what we’re used to).

In contrast, our market-driven approach has resulted in a wildly off-kilter ratio of specialists to generalists and for terrible geographic misdistributions in access. Physicians are a critical resource for quality, access, and cost, and we should manage their distribution—both in terms of specialties and geography— far better than we do. Just opening more medical schools and letting the chips fall is a terribly inefficient way of producing more primary care doctors for Nebraska or Oakland.

Secondly, the boldness with which the U.K. government supports its National Institute for Health and Clinical Excellence (NICE) and takes cost-benefit analyses into account before approving wildly expensive and low-yield devices and medications is admirable. We’ll need to do this eventually, of course, once we can figure out how to navigate the politics of “death panels.” There’s widespread acceptance from the U.K. public and medical profession—both understand the need to make tough choices. I’m envious.

This brings me to my second major observation: There really is a difference in cultures. The U.K. has a much more collectivist mentality regarding healthcare (and everything else). That may seem like an odd thing to say while the embers are still glowing in Tottenham, but when it comes to healthcare, there is a general agreement that “we’re all in this together.” If the system, operating on a fixed taxpayer-supplied budget, permits the widespread use of some hellishly expensive new toy but then can no longer guarantee high-quality basic care for everyone, people here see that as an unacceptable tradeoff. They’re right, of course.

The evidence for this is everywhere, but the most striking is in the attitudes toward aggressive care at the end of life. I’ve had the opportunity to witness some discussions that would have been inconceivable in the States, including elderly folks with a serious or terminal disease being told by their doctors that there is nothing more to be done. And the patients and families simply accept it! Contrast that with the U.S., and the inability of everyone—doctors, patients, families, hospitals, malpractice lawyers— to say “enough is enough.” I have no idea how we achieve the consensus necessary to change our approach, but our present path is unsustainable and—while seemingly righteous at one level—ultimately immoral.

My third big-picture observation relates to the differences between primary and specialty care in the U.K. and U.S. I’ll discuss the organization of hospital care—including the fascinating development of the specialties of acute medicine and ortho-geriatrics—in a subsequent post. For now, I’ll concentrate on the role of the general practitioner and the remarkably strict division between primary care and everything else.

As you know, the primary care system here falls on the backs of GPs, who are organized into groups known as primary care trusts. These community-based physicians are innovative in developing shared practice models, public health interventions, things that we’d call “medical homes,” off-hours coverage and more.

There is a bright dividing line between primary and secondary care here. I remember first hearing this when a UCSF colleague came to England on sabbatical a decade ago. “Do primary care docs follow their patients in the hospital,” I asked naively. “The average GP doesn’t know where the hospital is,” he quipped. Not quite, but pretty close.

In contrast to the GPs, who don’t come to the hospital, all the specialists are based at the hospitals, where they run clinics and subspecialty wards. There really aren’t any community-based pulmonary or endocrine practices, and multidisciplinary clinics are rare. So when the GP, working in his or her office, sees a complex diabetic or a rising creatinine, the question is: “Do I send this person to see the specialist (whom I’ve never met) at the hospital, and wait the four to six weeks for an appointment? Or do I do my best in the clinic?” Most times, they chose the latter. And it usually works out fine.

Interestingly, the GPs I’ve discussed this with generally like this division, which allows them to focus on their office practice and patients, and the systems they need to support them. (Ironically, the state of IT is far better in GP practices than in hospitals, since the primary care trusts purchased and implemented their systems as groups, largely bypassing the NHS bureaucracy). One healthcare policy leader who still practices as a part-time GP told me that this division has prevented GPs from becoming de-skilled and has preserved a non-specialist (and thus less resource-intensive) practice style in ambulatory care. It’s an interesting point, and you can’t argue with the bottom line: the U.K. spends 9% of its GDP on healthcare and we spend 17%, achieving outcomes that aren’t demonstrably better.

On the other hand, I really wonder whether this strict separation—one in which the GP rarely has the opportunity to work side-by-side with a subspecialist—de-skills the GPs in a different way, since they lack exposure to the latest subspecialty thinking. Who knows? As for me, I’d prefer being cared for in a multispecialty group practice, where the GP can walk down the hall and “curbside” the GI guy, as long as it was also one in which the GP was well trained and took pride in her ability to manage the vast majority of the problems herself, and in which no one operated under incentives to refer, test, and procedurize. As I listened to my GP friend, his description of letting specialists into the GP community sounded a little like how the natives on a secluded island must feel about letting in outsiders. Sure, we could use their know-how regarding clean water and catalytic converters, but how do we ensure that we don’t eventually end up with Fox News and the Kardashians? It’s a tricky balance.

Those are just a few of my initial observations. It’s a fascinating trip and I’m grateful to UCSF and the Fulbright program for supporting it, and to all my new friends here for being so open, forthcoming, and welcoming. There will be more to come on patient safety, hospital care, and other topics that seem interesting. Stay tuned.

***
Next week, we’ll be migrating this blog to another “platform” – one that doesn’t crash, allows for easier uploading of photos and videos, and won’t freeze when people try to add comments. Your RSS feed will continue to link to the new site, but you’ll have to sign up for a new email alert. All the prior blogs and comments will be preserved. I’ll have more specific information about the transition early next week, so keep your eyes open. Thanks for reading!

11 Responses to “Summer in London: First Impressions”

  1. Menoalittle August 14, 2011 at 1:33 am #

    Bob,

    The US HIT programs ought to learn from the UK NpFIT debacle, for they are not much different, eh.

    They are using the same devices manufactured by the same companies.

    HIT advocates from HIM$$ are active in both the UK and the US.

    They were not fit for purpose in the UK and are not fit for purpose in the US. They had not any vetting for safety and efficacy in the UK by MHRA, and have none in the US by the FDA.

    The one material difference I see is that the doctors in the UK rebelled against the meaningfully dangerous care record systems, whereas in the US, the hospitals retaliate against the complainers, declaring them disruptive, and do away with them by administration directed “peer” review.

    Finally, in the US, a courageous lawmaker has come to reason with all of this, recognizing the error promoting features of HIT as currently configured: http://smbiz.house.gov/UploadedFiles/Health_IT_Concerns_Sebelius_8.11.11.pdf

    It is likely that Secretary Sebelius will brush this aside as she supports the interest of the HIT vendors, who are also well positioned politically (especially in Kansas) and who have infiltrated the government payroll with advocates. Deja vu all over again.

    Best regards,

    Menoalittle

  2. Richard Smith August 14, 2011 at 3:43 pm #

    Good to catch up with you at the Cod, Bob, and I hope that you enjoyed “Betrayal.” We thought it marvellous. better than the version we saw at the National Theatre years ago.

    I’ve enjoyed your blog, and mots of your observations are spot on. But here some things that I interpret differently–but not necessarily correctly.

    1. There’s a general sense her that central planning of manpower has not worked well–because it takes so long to train doctors and because future need is hard to predict. General practice, particularly in poorer areas, was kept alive by doctors trained overseas, most of them from South Asia and many of whom didn’t want to be GPs. But you’re probably right that central planing has worked in giving the UK a much better ratio of primary to secondary care doctors than the US.

    2. The differences in income are greater than you suggest. (We Brits are even more embarrassed to talk about money than sex.) Doctors doing private practice a couple of days a week may well have incomes of £500 000, at least four times the average NHS salary for consultants. And many GP principals earn £200 000 a year, and remarkably as independent practitioners in the private sector have final salary, index linked state pensions, an extremely valuable asset.

    3. NICE has done well and is widely admired, but the present government seems determined to emasculate it.

    4. It’s true that the UK is more collective than the US—particularly in relation to the NHS—but I think that the stark difference in end of life care is a deeper cultural difference. Many people turn down heroic care not so that funds can be saved for others but because they feel the futility of pushing away imminent death.

    Other Brits may—and, I’m sure, will– think differently on all these points.

  3. Robert L Wears August 14, 2011 at 4:33 pm #

    I would emphasize Menoalittle’s comment on health IT in the US. Information technology is the only medical device (look at the FDA regulations — it meets the definition and the FDA agrees that it does) which does not undergo any form of the most minimal safety assessment prior to marketing and use.

    In particular, the health IT world seems remarkably uninformed by the advances in safety critical computing as it is employed in other high risk settings (eg, the military, flight control systems, rail switching systems, etc). While this approach is clearly not a panacea, it is tragic that we are not taking advantage of current knowledge and experience to make health IT both safer and more effective. The current US approach is wasteful, irresponsible, and dangerous.

    We would do well to learn from the experience of our cousins across the pond in this area (and many others).

    Best,

    bob

  4. Jo Bayly August 14, 2011 at 4:40 pm #

    Hi Bob,

    I enjoyed your blog and look forward to reading more.

    I just want to comment on one point, regarding front line engagement with patient quality and safety issues. I am a front line health care professional in the North of England, a physiotherapist, (actually working in palliative care) and would consider that where I work, we are all extremely well engaged with the national patient safety and quality agenda. I’m not sure where you saw people who weren’t engaged?

    Jo

  5. alan maynard August 14, 2011 at 6:54 pm #

    Idyllic view of general practice, which sadly is very light on performance data: need to probe those GPs you meet about this and how poor outliers have not been “sorted” Primary care run by corner shop tradesfolk, some of whom are excellent and some of whom lack this quality!.

    GP-IT good but not linked so poor system data to pursue the ungodly.

    Hospital IT e.g. hospital episode statistics or HES) quite good and with PRoms allows significant anlaysis, even if grossly underused by NHS managers/clinicians

    Physician regulation quite feeble by General Medical Council: still waiting for re-accreditation and national accreditation of traing in teh arts that lead to “license to kill”!!

    Slow development of registers: leader=cardio thoracic surgery. This despite advocacy of registers in 1803 by Thomas Percival (and Ernest Codman in US in 1915)!

    Workforce planning feeble as shown by perverse incentives and feeble use of potential to alter skill mix.

    WARNING: LOndon is not Uk and is not even England. Don’t get blinkered by the metropolitan mafia!!! You can always visit the People’s Republic of Yorkshire to be “confused” by facts!

    Have a nice stay but do exhibit sceptacaemia: defined as`”a condition of low infectivity. Medical school education can give life long immunity”

    Best Wishes

    Alan M

  6. Sarah Corlett August 15, 2011 at 10:59 am #

    Dear Bob

    Welcome to the UK. I’m sure you’ll have an interesting time! I like your take on the NHS (and the contents of an English fridge) so far. It’s always good to hear a perspective from someone outside the system. There are myriad voices from the NHS streets as well as the board rooms and seniors of course. You have probably heard of the ones below already but I like them as they make me feel I am not alone in thinking we are taking a turn for the worse in the NHS whatever its foibles (and there are many).

    Roy Lilley’s blog/ rant on the NHS (on the button and funny too). Here’s today’s offering:

    http://campaign.r20.constantcontact.com/render?llr=zfxea5cab&v=001vumIjKLl6–8uH_1KtA_mBFf451m2AylAxLzOZLu7KpTk90_gus1CDNoAHAY_lZKCWujweYRcIuLcc_LhcLxFwD81lCXYJ3-TNiRU2Q4FguPvCVS76QHi33Iptquf_fi Follow on Twitter or sign up to nhsmanagers.net for a daily email.

    Some polemics from GPs like jonathan tomlinson http://abetternhs.wordpress.com and ‘Dr No’ http://www.badmed.net/blog/1 and of course Keep Our NHS Public http://www.keepournhspublic.com/policybriefings.php. Not to mention Allyson Pollock, the bete noir of both this and the former Labour Government for her work debunking PFI etc etc. Leaves civil servants and ministers in a state of apoplectic spluttering.

    Public health has its own view of the world of course (I’m a PH physician) but that’s another story..

    Enjoy your trip

  7. Alison Spurrier August 15, 2011 at 2:30 pm #

    Hi, I’m a gen med nurse. I found your comments re ‘end of life’ care in The State of interest. Here, many peoples dont want to embark on a course of treatment which will only have limited benefits and means more pain and suffering for the individual. Is it that us Brits have a more realistic attitude towards death and dying and know the right time to say,’Enough is enough’, and hope for a more peaceful demise? In my experience these decisions are not of a financial nature, but are difficult decisions made by caring individuals whos’ aim is the comfort,

    dignity and ultimate well being of the patient.

  8. Dr Am Ang Zhang August 16, 2011 at 10:53 pm #

    Welcome to England & Scotland & Wales.

    Some of us wants to keep our NHS public and I have my own blog, the Cockroach Catcher.

    The Cockroach Catcher Blog

  9. Ben Toth August 23, 2011 at 5:04 pm #

    Hello Bob

    Just a couple of small quibbles with your analysis

    1 Off hours coverage has got worse in recent years since GPs were freed from responsibility to provide them.

    2 GP IT systems are well developed. That has been true for a long time and the reasons why are various. But one reason is that successive governments gave GPs money to buy systems

    The peculiarities of the British healthcare system are fascinating. Daniel Fox ‘Health policies, health politics’ and Frank Honigsbaum ‘The Division in British Medicine’ are worth a read

  10. Richard Blogger August 25, 2011 at 4:53 pm #

    “The U.K. has a much more collectivist mentality regarding healthcare … If the system, operating on a fixed taxpayer-supplied budget, permits the widespread use of some hellishly expensive new toy but then can no longer guarantee high-quality basic care for everyone, people here see that as an unacceptable tradeoff. They’re right, of course.”

    Just one example from the distant past. In 1990 I worked as a researcher in the Physics Dept at Nottingham University where the MRI technique was developed (yeah, yeah, I know there are some yanks who say *they* invented it, but our very own Prof Sir Peter Mansfield FRS was awarded the Nobel prize for MRI so that proves our point, OK?). Anyway, at that time, commercial versions of MRI were incredibly expensive so the hospital just over the road (conveniently called the University Hospital) was part of a partnership of hospitals in the East Midlands which shared an MRI machine. This was housed in the back of a container lorry (I’m sure there is a US translation of this somewhere…) that was driven between the hospitals on a regular schedule. As you say, the NHS has a “collectivist mentality”, if one hospital could not afford the machine, then several would pay for it and find a way to share it.

    [My research wasn’t with the MRI group, although it did involve a large superconducting magnet. However, every now and again an NHS patient, taking part in a study with the MRI group, would get lost and knock on my lab door. The 25mm bore of the magnet in my lab limited the range of the bodily parts that could be inserted into its magnetic field. However, the 4K temperature in the magnet persuaded most patients that they would be better off finding the MRI suite!]

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