The U.K. is about to pass into law a National Health Service overhaul so extensive its chief says it’s visible from outer space and so controversial nine out of 10 family doctors don’t support it.
The big idea: put doctors in charge.
The country’s state-run health service, long derided for its inefficiencies, will require general practitioners to watch costs and show results under a bill awaiting Queen Elizabeth II’s signature to become law.
Prime Minister David Cameron’s government devised the change to better serve an aging population plagued by expensive chronic conditions like diabetes at a time when funding is tight and the economy struggles to grow.
The transformation of the health service, whose annual spending more than doubled to 102 billion pounds ($162 billion) in the past decade, will be such a change that “you could probably see it from space,” David Nicholson, chief executive of the NHS commissioning board, told a NHS Alliance conference in 2010, according to a transcript from Health Policy Insight.
In addition to scrutinizing financial performance, the new system may attract more private companies to help local GP practices manage their new responsibilities.
The bill also allows NHS hospitals to increase their capacity for private patients, who self-pay or have private insurance, from 3 percent to 49 percent. The private sector accounted for about 16 percent of U.K. health-care spending in 2009, according to the Organization for Economic Cooperation and Development in Paris.
Companies including Aetna Inc., UnitedHealth Group Inc., McKinsey & Co., KPMG and Ernst & Young LLP have done work for the NHS and are in a position to help physicians and organizations as they assume new duties, say public health researchers.
“This is a massive transformation,” said Piers Ricketts, a partner at KPMG’s health-care practice in London. “We and other similar firms are well-placed to advise and help.” Cigna Corp. also said it expects more demand for its services.
The NHS, created in 1948 to provide a taxpayer-funded health system for all, is the world’s fourth-largest employer after the Chinese Army, the Indian railway and U.S. retailer Wal-Mart Stores Inc. About 32,000 family doctors in England work with the NHS, conducting 800,000 patient visits a day, according to the U.K. Department of Health.
Many doctors object to the changes. A poll by the Royal College of General Practitioners, a professional body, found that nine in 10 family doctors don’t support the measures.
Laurence Buckman, a north London family doctor and the chairman of the British Medical Association’s General Practitioners Committee, says the new system will impose “byzantine” control and more bureaucracy on doctors.
Running a medical practice is “a very select hobby” for the 5 percent to 10 percent of GPs “who are interested in this,” said Buckman. A majority would rather treat patients than deal with administrative and financial demands, he said.
Others are more optimistic. Rebecca Rosen, a family doctor in southeast London and a health researcher at the Nuffield Trust, says the changes have an “inherent logic.”
The NHS spent 102 billion pounds in the year that ended last April, compared with 44 billion pounds a decade earlier, the health department said. A government review of NHS spending concluded that its budget would not increase much beyond inflation before 2014-2015, Nicholson told employees in an October 2010 letter.
Money Is Tight
He also warned that the NHS had to save between 15 billion and 20 billion pounds in that period to offset rising demand as people live longer and with chronic health conditions.
Employment is already falling. The NHS staff fell by almost 20,000 from September 2010 to September 2011, the largest drop in a decade, Sarah Dahlgren of the U.K. Health and Social Care Information Centre said today.
“The real goal is driving productivity improvement and quality of care during this period of austerity,” says David Stout, deputy chief executive officer of NHS Confederation, which represents organizations within the health service. “The NHS is continuing to get real terms growth, a tiny amount, but demand and costs rise faster than that.”
Cameron’s Conservative Party, which has cut government spending, promised not to reduce the NHS budget during the 2010 election campaign.
Two months after taking office, Health Secretary Andrew Lansley proposed to delegate power to local doctors, streamline bureaucracy and enable patients to choose doctors. Doctors would focus on patients’ health, the system would be “more responsive” and management costs would be lower, Lansley said.
No More Power
“The GPs thought they were going to get more power and run it their own way,” says Alan Gavurin, managing director of Damson Health, who has advised GPs for more than 20 years.
Lansley’s plan abolishes the country’s 152 primary care trusts, or PCTs, which manage local health budgets and contract with doctors for routine medical care, at a cost of 2 billion to 3 billion pounds. PCTs would be replaced by 244 clinical commissioning groups, or CCGs, which would purchase primary care from general practices, employ fewer people and be headed by boards that include at least one GP, a nurse and a specialist.
The commissioning groups are already forming. Forty percent of staff in Rosen’s PCT have been fired, she says. She is now vice chairman of the PCT’s successor, the Greenwich clinical commissioning group.
Some doctors like Rosen welcome the greater responsibility.
“I’ve got some experience with this but most of my colleagues don’t,” says Rosen, who has done research on health services for 20 years.
‘Politics Over Wisdom’
Lansley’s initial bill stalled in the House of Lords last year. After further consultation and hundreds of amendments, oversight provisions were included and the bill revived.
“As the politics have taken over from wisdom, the plans have got more and more complicated and the range of opportunities for clinical decision-making have narrowed and narrowed,” Buckman says.
The British Medical Association opposes the changes, along with the Royal College of General Practitioners and other professional bodies.
“We’ve got an end result that nobody outside the government is satisfied with,” says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine.
The House of Lords passed the bill on March 19 and the House of Commons backed the Lords’ amendments to the bill the next day. To become law, the bill must now be given royal assent by the queen, who is expected to sign it before parliament goes on its Easter break on March 27.
Lansley has faced limited public protest over the reorganization plan. A Guardian newspaper poll in February found that 52 percent of the public didn’t support his plan. In February, a 75-year-old former union representative harangued him as he arrived for a meeting at No. 10 Downing Street, the Prime Minister’s official residence.
“If Lansley had managed the politics better, no doubt he’d have had less objections,” Damson Health’s Gavurin says. “There are 30,000 GPs. They never agree on anything, but he’s managed to upset huge numbers of them.”