Sunday, July 27, 2008

American doctor says NHS is best.

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.


Anonymous said...

Recently published data on certain cancer survival rates seem to be at odds with some of your assertions. See for example
or the original article in Lancet Oncology 17 July 2008.

Terry Hamblin said...

It is quite clear that this comparison is invalid. The study showed the US had the highest five-year survival rates for breast cancer at 83.9% and prostate cancer at 91.9%. The UK had 69.7% survival for breast cancer, just above 40% for colon and rectal cancer for both men and women and 51.1% for prostate cancer.

But do the comparison a different way and you find that deaths per hundred thousand controlled for age and sex and virtually the same. Prostate cancer may be overdiagnosed by screening tests. The cancer is there alright, but it doesn't actually need treatment - certainly not at the time. A supply driven service will treat even when there is no need because there is a financial incentive to do so. It's a bit like treating stage 0 CLL. For breast cancer the same may apply, but we are talking about earlier diagnosis. he patient may live no longer, she just knows she's got cancer for longer and apparent 5-year survivals just start earlier in the disease.

Colorectal cancer deaths in the UK are certainly poorer than they should be. It might be due to greater embarrasment about 'bottoms' than in France, where there is a tradition for medicine by suppository.

Anonymous said...

If you read the Op Ed piece in the NYT 7/24 that I rec'd you would see the writer's opinion of why service-driven care ends up costing more, without necessarily improving overall outcomes.

Proactive care...when validated...likely is the most cost-effective way to improve overall health of a population.

There is much merit in his arguments, and also a lot of merit in your concerns about bureaucracy.


Terry Hamblin said...

Yes, the Op Ed piece did inform my thoughts about this.

Anonymous said...

Berwick is an idiot.

America has the best healthcare in the world; there is no disputing it.

Indicators that purport to show that the US health care is somehow worse than a country like the UK (which doesn't allow rituximab for CLL, avastin for colon cancer, etc. etc., and where waits for care are legendary) miss the big picture.

The UK does not have large rural areas such as the Southwest, where Indian populations are so remote that healthcare is miles away. The UK doesn't have 20 million illegal immigrants who don't have health insurance because they are here illegally. The UK doesn't have Chinese populations in cities such as San Francisco, which has a warren of dwelling places that are so removed from the regular population that the census bureau has no clue as to how many people there are in Chinatown.

The liberals in the world want the US to suffer like the rest of the world, having a system where life-saving drugs are not available because they are too expensive for the government to pay for, and if a patient wants to pay for the drug themselves, the government gets angry and denies the patient any NHS care at all.

Let the rest of the world stew in inadequate care. The US leads the world in drug research, in drug patents, in the use of cutting edge therapies and surgeries.

The rest of the world plays catch up to the superior US system.

That is a fact. All of the liberal nonsense is just that, nonsense.

Terry Hamblin said...

Well that should lead to a lively debate. I have now read the CONCORD article in Lancet Oncology. The article is written by epidemiologists who are a lot more satisfied with their data than I am, but even they can see the flaws in their system. Our American friend, who thinks that the American system is the best in teh world might be surprised to find that Cuba has the best survival figures. Japanese figures on colon cancer surpass everyone, but diagnostic criteria are diffrenet there. We would call some of their cancers benign adenomas. Although British breast cancer 5 years survivals afer far worse than those in Australia, if only metatstatic cancer is snsidered, th figures are the same, so it can't be down to the availability of new chemotherapy.

Like the US, the UK has many illegal imigrants (some put it proportionately as large as in the US) and many of them settle in closed communities like the Chinese in California. The number of Bangladeshis in East London is unknown, though we do know that they don't avail themselves of the health service available. Prostate cancer sufferers survive a very long in America, but then it is 4 times as common in the UK, with about the same numbers per 100,000 dying. Why is this? Because we don't screen for PSA routinely and therefore we don't pick up teh low grade cancers that don't need treatment and don't kill you or cause symptoms.

It is not true to say that the US leads the world in drug research. Some of the biggest companies are British, French, German and Swiss. American clinical trials are often substandard copmpared with those in Europe. While American Universities have produced exciting research, 4 of the ten top universities in the world are British (Oxford, Cambridge, Imperial College London and University College London. (6 are American, but it is 5 times larger in population).

SICKO seems to think that Cuba has something to teach Americans in regard to health. I disagree. I think their figures are fraudulent. But then I wouldn't trust any of the figures produced by Cancer Registries.

Burke said...

Doctor Hamblin,

When you retired in March, you posted an article enumerating some NHS abuses and ended with the statement that you were so glad you no longer worked for the NHS. Not long afterward, you posted another article about "NHS nonsense."

I got the impression you weren't so high on socialized medicine.

Terry Hamblin said...

Not so keen on American medicine either.

Anonymous said...

You must be glad not to live in America! Obviously billions agree with you since illegal aliens have been leaving by the millions, no one is applying to come to the US anymore. America is emptying out! Soon, it will be totally abandoned!

Obviously, I am joking. We have millions of illegal aliens here, the waiting lines to emigrate to the US are full, and waits are long. I wonder why, since everyone 'knows' America is a terrible place!

I'm sorry but socialized medicine is inferior to the US system.

You didn't comment on the fact that more research is done here than anywhere else in the world, more drugs are developed here than anywhere else in the world, and CLL care is better here than anywhere else in the world.

Or are you still convinced that chlorambucil is superior to rituximab, Campath, Hu-Max, vaccines, lumiliximab, revlimid, gene therapy, and all the other drugs developed or used in the US?

Where would you be as a doctor if the US didn't exist? Better off, or worse off?

I'd guess better off.

Anonymous said...

Let's look at the drugs you CANNOT get (or have been delayed years behind the US) in the UK:

Aricept for Alzheimer's

Every drug for osteoporosis except alendronate (which 1/4 of Brits cannot take).

Infliximab for Ankylosing Spondylitis

Sprycel, for CML

Cryotherapy (surgery) for prostate cancer

erlotinib [Tarceva], which is extending lives of lung cancer patients

Velcade for myeloma

abatacept for rheumatoid arthritis

Rituximab for first-line CLL

Avastin and Erbitux for colon cancer

Temoda for melanoma and brain cancer

Stutent for kidney cancer

Xolair for asthma

Lucentis for blindness

Macugen for blindness

Avonex for multiple sclerosis

Bottom line: This is socialized medicine at its worst. It's good enough for the Brits, but not Americans, let's face it.

We demand success, not excuses that satisfy the Brits.

Terry Hamblin said...

America, a former British colony, does do a lot of medical research, but remember it has five times the population of the UK and many times the area and natural resources. Of the six drugs you mention for CLL, four are monoclonal antibodies which were invented in the UK. Campath is a drug invented in Cambridge University, England. Humax is a drug invented by a doctor at the University of Southampton, England.
Revlimid, is a thalidomide derivative and thalidomide was a German drug. There is no evidence that lumiliximab has any advantage over other monoclonal antibodies.

People emigrate to the US because people are richer there than they are in most of the world. Strange to say they come to Europe too for the same reasons. They don't come to be uninsured in the American health care system, but lots of Africans and Asians turn up in Britain to take advantage of free health care.

To talk about the American system as if it were not itself 'socialized medicine' is hypocrisy. The American government spends proportionately more on healthcare than does the British government. It just gets a poorer deal for its money. 20% of the American healthcare budget goes in administration compared with 5% of the British.

American drug companies have not noticibly more succesful in bringing new drugs to market than European companies like Roche, Aventis, GSK, Astra-Zeneca, Bayer, Boehringer and Novartis.

You mention vaccines. Well, the idea of idiotypic vaccines for CLL (like MyVax) was one developed in the 1980s by Ron Levy in Stanford and George and Freda Stevenson in Southampton. They worked closely together and were jointly awarded the Armand Hammer prize for Cancer Research. Personally, Even though I was involved in their development, I don't think they work yet, but undoubtedly it was a clever idea that may yet yield a dividend. However, my point is that medical research is international. The best thing about America is that it rewards enterprise, but the talent comes from every nation under the sun.

Of course, America has some of the best doctors in the world, but I can tell from my correspondents that it has an awful lot of duds as well. Don't think that I haven't had opportunities to work in the American heathcare system, but on the whole I would prefer to stay in Europe. There are lots of things wrong with the NHS but taken all in all I would prefer to work in the UK than in America.

Terry Hamblin said...

Anonymous #2

You must have been misinformed. All those drugs are available in the same way as they are in the US - to those with health incurance. Some of them are even available to those without health insurance under certain circumstances - and with no co-pay.

The great debate at the moment is whether and how expensive drugs with no overall survival benefit, though with promising early results should be made available to patients at no cost to them. It is a debate being held all over the world; not just in the UK.

Anonymous said...

Yes, but you don't address my main point. Drugs are available in the US that are not available in socialized medicine companies.

When the government is the single payer, then health care needs to compete with defense, education, road construction and everything else. Obviously with those constraints (you are fond of mentioning what a low percentage the UK spends on health care), then something has to give.

Care is thus rationed. Patients are forced to wait for important tests and surgeries. You are as aware of that problem as I am.

I am facing having to have a 'quick' series of appointments. I have no problem getting them. I wonder how long I would have to wait in England?

You also fall into the trap of calling your health care 'free'. Of course, it isn't free. It is paid for by taxes.

It's best to have private industry do as much in an economy as possible. Look at the auto industry in the US (or the UK). Before the Japanese (and other countries) started selling cars in large numbers in the US, the domestic automakers really had little competition. Now, the domestic market in the US has less than a 50 percent share. Cars are better, they last longer, and people are more satisfied with them.

Health care needs to be the same way. An open marketplace (open to US drug makers, European drug makers, etc) means that only the best will reach large scale adoption. You can quibble about 'me too' drugs but auto makers manufacture 'me too' cars all of the time.

You love England and want to stay there. I'm glad. England is an OK place. I wouldn't want to live there, and I prefer many other places over England, but you almost speak correct English, and we get the best of your television programs, and some are great indeed (particularly Inspector Morse).

I am a conservative. I like the things the way they are in terms of health care and the options I have. I'll bet my last dollar that I have more possible treatments than are available to the average Brit.

(BTW, I've never claimed the US is perfect. We have WAY to many liberals.)

Terry Hamblin said...

If I have health insurance - which is no more expensive than in the US - then I have access to all the drugs that you have access to. Appointments with real experts are instantly available. There is no waiting list. But only 20% have health insurance.

In the US nearer to 80% have health insurance therefore it is a matter of how to to treat the uninsured. The astonishing theing is that the UK government spends 8% of GDP is used for the 80% where the US goverment spends 11% of GDP to pay for 20% (although in truth the quality of some health insurance policies is so poor that they have to be supplemented by the government.)

Many of the criticisms you make are out of date. Cancer patients cannot wait more than 2 weeks to see a specialist. and even routine elective operations are available much sooner than was previously the case. My daughter saw a dermatologist withing 3 weeks of referral, for example - I remember 6 month waits for this speciality in the past.

I notice that Medicare is withrawing approval for erythropoietin for cancer patients. The truth is that health care has to be paid for even if it is free at the point of contact. Politicians would rather reduce taxes and most of us think we could spend our own money better than the government. In fact the government ought to have advantages of bulk purchasing, discounts as a major customer, flexibility in moving staff to where they are needed - just like any other large company.

Instead they keep within budgets by rationing. At least the rationing is a lot more reasonable than it used to be. Organisations like NICE are a brave attempt to avoid patients being hoodwinked into buying drugs that don't work are only work for a short while at tremendous cost.

I am not happy with all their decisions and I don't think the market has coped well with expensive drugs. For example, why should patients not be able to take out insurance policies solely to pay for expensive drugs - ones that exceed the NICE guidelines of >$60,000 for an extra year of good quality life.

Open markets are all very well, but there are no such things. Governments always interfere in markets with regulations and in health they always will. The FDA prevents some agents from reaching the market, for example.

I agree that some people in England almost speak correct English - I despair of the very many who don't; but your problem in the US is greater in this respect. I am afraid that nowhere is this more manifest than in Hollywood films. I have to have the subtitles switched on to enable me to understand them.

Anonymous said...

First of all, regarding the English comment, I was joking. Spelling labor, color and flavor with an extra 'u' is different, and we spell it without the u because of Webster, of the American dictionary fame (as I recall).

Of course government is involved in every aspect of people's lives. Unfortunately, the trend is getting worse and worse. In California, the LA City Council has banned new 'fast food' places because of the obesity problem. I can buy a salad or a chicken sandwich (or even a veggie burger or a tuna fish sandwich) at McDonalds and their clones.

There is even a guy in the US who lost 200 pounds eating sandwiches from a fast food place and is now a pitchman for the company.

I called the LA City Council and they defended their actions. I did point out that they are limiting freedom to choose and act like adults, but they ignored me.

A law was proposed that everyone in or near a body of water must wear a life preserver. Champion swimmer? Makes no difference.

Seat belt laws. Motorcycle helmet laws. 'Hands-free' only cell phones while driving (though text messaging is still OK!). All pets must by law be spayed or neutered, or you pay big fines if you are a dog breeder. New gizmos on tires at $200 per to make sure your tires are inflated. Gay marriage will now be taught in schools as acceptable and to be celebrated. State holiday proposed for gay city councilman from San Francisco. Lights must be turned on when one drop of rain hits your windshield.

I could go on but you are correct in saying that government is running more and more of our lives.

I just want to slow down the march to oblivion.

Terry Hamblin said...

Sounds like things are better here than there. Actually, it's quite easy to learn English spelling, if yoy can't stand the way government intrudes in your like in America.

Pat said...

Very interesting discussion of the health care industry and government ownership of process and product. But somewhere along the way the discussion took a right turn (no pun intended) and from then on it was just circles and more circles. Thank you Dr. Hamblin for your thoughtful presentation of the issues from a knowledgeable and international perspective.

Anonymous said...

A small correction about your leading comment on Jul 31. American is not a former British colony! America is comprised of 50 states covering a geographical area not imagined during colonial rule. You may claim that approximately the first 13 states were partially colonized by your ancestors but certainly not all 50 states.

Terry Hamblin said...

Well, sorry about the joke! Actually, what is now the United States of America was originally colonized by England, France and Spain, but most of it was occupied by what you now call Native Americans - a people of Mongolian extraction who presumably reached it from Asia. By the time the organization that became the United States set itself up as an entity, England had colonized the whole of the British Isles, including Ireland and assumed the name Britain. As you say 13 states rebelled against the British crown and established themselves as an independent state. These States began an expansion southwards and westward in the same colonizing spirit that culminated in the genocide of the Native Americans. Meanwhile, Britain was still left in possession of over half the continent despite an unsuccessful attempt in the early part of the nineteenth century by America to seize the rest of the British colonies there.

Although many Americans claim British extraction, the country has given a welcome to people - especially the poor and dispossessed from all over Europe, Africa, Asia, and Central and South America.

It is a mistake to question the ethics of our ancestors who lived at a time of different moral assumptions, so I forebear to draw attention to the fact that the number of individuals of African extraction in America owes less to the generous and welcoming attitude of “Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tossed to me, I lift my lamp beside the golden door!" and more to a rather darker motive – but one that we British shared in until William Wilberforce and his colleagues saw the light.

With the same motive of enlightenment and without wishing to criticize in any way, I ought to draw attention to the fact the ‘comprise’ cannot be used as a synonym of ‘consist’ or ‘compose’. The correct usage in both our languages would be ‘America comprises 50 states’ or ‘America is composed of 50 states’ or ‘America consists of 50 states’.

Anonymous said...

Thank you for your comments on my usage 'of comprise' . I consulted Webster's Ninth New College Dictionary and found that there are three common usages of comprise, the third of which is COMPOSE, CONSTITUTE as in "A is comprised of B." The following usage warning listed in the dictionary is of relevance.

"Although it has been used since the late 18th century, usage 3 (above) is still attacked as wrong. Why it has been singled out is not clear, but until comparatively recent times it was chiefly in scientific or technical writing rather than belles lettres. Our current evidence shows a slight shift in usage: usage 3 is somewhat more frequent in recent literature use than earlier usage. You should be aware, however, that if you use usage 3 you may be the subject to criticism for doing so, and you may want to choose a safer synonym such as compose or make up."

As the responder who confessed to being able to understand the mathematical equations associated with global warming, you now know that 'comprised of' is part of my technical vernacular.

Terry Hamblin said...

You will see from my profile that Fowler's Modern English Usage is part of my bedtime reading. Fowler's comment on this is, "This lamentably commonuse of 'comprise' as a synonym of 'compose' or 'constitute' is a wanton and indefensible weakening of our vocabulary.

I was only nit-picking in response to your nit-pick about whether the US was a former British colony.