Health care reform: UK v US
Author: Ruth Thorlby
As the coalition government begins to consult on its radical proposals for NHS reform in England, the boldness of the ideas have begun to be noticed internationally. The ideas contained in the recent white paper, Equity and Excellence: Liberating the NHS, were the subject of much discussion at a recent meeting of policy-makers and academics in Boston, sponsored by the Nuffield Trust and Commonwealth Fund (check back shortly on these pages for a longer write up).
This was partly due to a sense of shared excitement and apprehension about change: the US Congress has recently passed its landmark health care reform act which envisages change to all areas of the health care system and, like the UK, still faces much uncertainty about the health of the economy.
Although the two countries have very different health systems and differing goals for reform – the US is hoping above all to extend basic health care coverage to millions of uninsured people – there were some powerful themes in common emerging from the discussion.
This is partly because a secondary aim of health reform in the US is to contain costs (which have seen relentless rises in the cost of health insurance premiums, driven by price-hikes from hospitals and other providers) and address the increasing fragmentation of care.
Many of those at the meeting agreed that the delivery of high quality, efficient healthcare will hinge on the willingness of clinicians to act not just in the best interests of their individual patients but care for patients across organisational boundaries, as well as acting as custodians of scarce resources.
It is this idea that is at the heart of the government’s plans for the NHS.
There was much debate about how to achieve this. There is, obviously, much greater reliance on the market to deliver reform in the US and there are some examples of spontaneous health plan initiatives to incentivise primary care physicians to find better quality and value for their patients – very similar to GP commissioning.
In one example discussed at the meeting, physicians had already switched their patients to a better value hospital, but ominously, the biggest and most powerful hospital providers in the area were refusing to take part.
NHS Trusts should face stronger incentives to cooperate as the overall NHS budget is fixed, but it will be a challenge to design incentives that ensure good cooperation across institutional boundaries in the NHS, especially if competition is the government’s favoured approach for provider reform.
The other model that has long been of interest to the NHS is the providers of high quality, integrated care.
What is striking about examples, such as Geisinger or Kaiser Permanente, is their comparative rarity.
Competition has not automatically produced integrated care or high quality leadership and positive cultures within organisations in the US, a message which the new government would do well to heed.
There was general agreement that there needs to be more effort on supporting physician leadership and creating the desired culture within organisations. This requires a focus on professional and organisational culture and a much more sophisticated understanding of what blend of government, competitive and regulatory pressures will work best.