Bob Wachter, on sabbatical in England, has been blogging about the National Health Service. In his latest post, noting Donald Berwick's romanticism about the NHS and the political consequences he reaped, Bob is not so romantic. While acknowledging many of the negatives of the NHS he finds a few things to like. Let's look at some of those and decide how likeable they really are.
A GP can make more than a surgeon, and brings home about 20% more than a subspecialist. (We aren't told how much that is and how it compares to primary care in the US). This is largely due to a big P4P incentive implemented by the NHS in 2004. The incentive, as Bob portrays it, is like our own system on steroids:
In 2004, the NHS negotiated a new contract with GPs, which included a “Quality and Outcomes Framework” (QOF), an unprecedentedly far-reaching pay-for-performance system in which GP practices could earn substantial sums based on performance on over 100 quality measures...
But the most prominent wall decoration is a large white board, located in the practice’s main thoroughfare, its grids filled with data on the group’s performance on the QOF measures. All the doctors, nurses and staff track these numbers daily because their livelihood, literally, depends on them. In addition to tracking process and outcome data via the white board, the practice’s sophisticated computer system allows caregivers to track their adherence to evidence-based quality measures and to see how the practice is doing against benchmarks and bonus thresholds.
Well, you can just imagine the distraction this creates away from real quality and clinical skill along with other unintended consequences. I have blogged many times before (and cited evidence) on the fallacy of performance as a surrogate for quality. (In the above quote I wish Bob had put the word quality in quotation marks). Beyond that, recent evidence suggests that even the effect on performance of P4P incentives is modest at best. The same was found to be true for the NHS incentive in particular in this NEJM study. More than that, under the British QOF incentives there was deterioration in adherence to uncompensated measures.
And there was this tidbit:
Moreover, the NHS limited GP practice hours to 8 am-6:30 pm, weekdays only, creating alternative ways (mostly through a series of urgent care clinics and, of course, through emergency rooms) for patients to receive after-hours care.
GPs in the NHS apparently like this, but can you imagine the US government setting your practice hours?
Finally this, speaking of the GP group Bob toured there:
..they review every case in which a patient goes to the ED, is admitted to the hospital, and is referred to a subspecialist.
Yes, the decision to refer even a single patient to a cardiologist or nephrologist needs to be defended. As far as I could tell, this is not because the costs of subspecialty consultation come out of the practice’s resources (although this may soon change, as the Cameron government’s plans to turn over most of the healthcare budget to GPs, called “commissioning,” are rolled out over the next few years). Rather, it seemed to me to be an issue of professional pride.
Can you imagine a US primary care practice reviewing every one of its subspecialty consults? They wouldn’t have any time left over to see any patients.
These reviews flow from the UK’s overall care model, which requires that all patients go through their GP in order to access subspecialty care and most sophisticated tests (one vivid example: a GP cannot order a CT scan or MRI—they need to be ordered by subspecialists). They don’t call this “gatekeeping” here, but that’s precisely what we would call it in the US.
Yes, gatekeeping. Remember the days of heavy managed care? Again, on steroids.