Donald M. Berwick, MD, MPP, FRCP is President and CEO of the Institute for Healthcare Improvement (IHI) and, is one of the America’s leading authorities on health care quality and improvement issues. He is also clinical professor of pediatrics and health care policy at the Harvard Medical School. Dr. Berwick has served as vice chair of the U.S. Preventive Services Task Force, the first "Independent Member" of the Board of Trustees of the American Hospital Association, and as chair on the National Advisory Council of the Agency for Healthcare Research and Quality. An elected member of the Institute of Medicine (IOM), Dr. Berwick now serves on the IOM’s governing Council. He served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Co-chaired by the secretaries of health and human services and labor, the Commission was charged with developing a broader understanding of issues facing the rapidly evolving health care delivery system and building consensus on ways to assure and improve the quality of health care.
Dr Berwick has written a piece in today’s BMJ that praises the British NHS far more than I would praise it. He calls it one of the outstanding human endeavors of modern time. At a time when successive government in the UK have sought to distance themselves from taking the blame for the deficiencies of the NHS, he claims that it is just because of its national scale and indebtedness to general taxation and consequently its subjection to political debate that gives it its strength and appeal.
It operates, he says, from the premise that health care is a human right. He contrasts this with the attitude in America where people ask, “How can health care be a human right? We can’t afford it.” As a result one American in seven does not have health insurance. Common humanity will not allow people to go completely without, so in America there is the safety net of Medicare and Medicaid, the VA, County Hospital ER rooms and measures for children etc, which are such an inefficient means of delivering health care that the US government ends up spending a greater proportion of the GDP on their bit of health care than the UK government spends on the whole of the NHS.
How is it that the US spends 17% of GDP while making healthcare unaffordable as a human right while the UK spends less than 9% and insists that it is a human right? You might go for the obvious answer that the 17% buys better quality, but in terms of outcome measurements that is simply not true. In almost every outcome measurement, whether it be longevity or infant mortality, the UK outperforms the US.
The UK and the US operate completely different models of healthcare. In the US it is supply driven. Someone makes a better mousetrap and everyone flocks to buy it. Someone else makes one on the same principle but makes it cheaper and purchasers switch to that. Suddenly there are a thousand mousetraps and they compete in the marketplace on the basis of cost and efficiency. Advertisers extol their color, shape, cost and kill rate. The consumer has choice.
In the UK it is needs driven. Money is allocated by government of the basis of how many people there are and how much sickness they have. Choice is limited, but experts decide not only what possible treatments there are, but also which is the most cost-effective. There is threshold beyond which the purchaser will not go; if it costs more, you can’t have it. The process of choice is transparent and challengeable in open court, but there is no mechanism to drive prices down.
The UK model sounds bureaucratic and therefore expensive, but in fact it is not. Administrative costs comprise 20% of the American healthcare bill, but only 6% of the UK bill.
You’d think that we British would be delighted with the bargain that we are getting, but we complain. In a restaurant we consume overcooked vegetables and tough steak without demur because complaining is not a very ‘British’ thing to do; but we moan about the NHS. Those who have been treated by it usually have nothing but praise for their experience, but somewhere in the British psyche is the thought that anything the government runs is bound to be hopeless.
Within the NHS we are sick to death of reorganization. One of the consequences of the complaints is that government reorganizes the service. I was appointed to be head of my department in February 1974. When I needed more facilities I went to the head of the local authority’s health committee and made my case. Two months later that had all gone and we were employees, not of the local hospital, but of the Wessex Regional Health Authority. After that e were run successively by the Dorset Area Health Authority and the East Dorset District Heath Authority. Then Wessex was abolished and we were part of the South West Region, run from Bristol, a town 100 miles away with no public transport link and a two hour drive by car. Then we had the Somerset and Dorset Strategic Health Authority based at Taunton, a small town 70 miles away, again with no public transport link and three hours away by car down country bumpkin roads. The purchasing and providing of health care was split so that we became dependent on ‘fundholder’ general practitioners while we became a ‘Foundation’ Trust. Then fundholders went and we had small Primary Care Trusts which soon amalgamated into large Primary Care Trusts and we dropped the ‘Foundation’ and became a NHS Trust. Soon we are to have Polyclinics rather than GP surgeries or perhaps in addition to. Small hospitals have become GP hospitals and will soon become the base for the Polyclinic.
Despite all these changes the same people are running things. Job titles have changed but the function stays much the same. Every reorganization is accompanied by a new logo and new headed notepaper. So please! A moratorium on reorganization!
Berwick has special praise for British General Practice or as we must now call it, Primary Care. This has changed from a reactive service to a proactive service. Last week I received an invitation to have a pneumovax inoculation. I don’t have weak lungs, I have never smoked, I don’t get chest infections, but I am 65. The GP obviously gets paid a bonus for every 65-year old he recruits to the program. It costs me nothing so I might as well go, but what’s next? Routine colonoscopies every year? Free hot water bottles for the winter months?
Berwick recognizes that the NHS is not perfect and has some prescriptions for us.
1 Patients should keep their own records and be involved in their own illnesses – nothing about me without me.
2 No more restructuring. Hear! Hear!
3 Keep it local.
4 Concentrate on Primary Care.
5 Don’t put your faith in market forces
6 Avoid supply driven care like the plague
7 Develop an integrated quality assurance system.
8 Heal the divide between doctors managers and politicians.
9 Train healthcare workers for the future not the past. I agree I was trained to look after TB and rheumatic heart disease, conditions that beset Britons in the 1930s.
10 Be a Heath service not a Disease service.