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.

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