A Time For Revolutions???

The Role of Clinicians in Health Reform
Source: New England Journal of Medicine
July 22 2009

William Beveridge, the economist whose 1942 report led to the founding of Britain's National Health Service (NHS), famously said that "a revolutionary moment in the world's history is a time for revolutions, not for patching."1 Given the combination of the global downturn and the time bomb that is health insurance costs, there is no denying that health care in the United States has reached such a moment. This matter is too important to be left to the politicians and policymakers; there is an urgent requirement for professional clinicians to step up and lead the debate.

President Barack Obama has brought health care reform to the forefront of people's minds, and it is now a matter of when, not whether, change will come. Repeatedly quoted statistics — on the numbers of uninsured Americans, for example, or the high, rapidly growing expenditures on health care — leave no room for ambiguity, and groups across the political landscape recognize that the U.S. health care system is unsustainable in its current form.

Every country in the developed world confronts a similar challenge right now: finding a way to create a well-resourced but sustainable system that provides care of the highest quality to those who need it. One would be hard-pressed to find credible opponents — regardless of their political stripe — to the goal of providing "universal health care." The disagreement arises when the discussion turns to the best way to achieve this aim. Each country needs to discover the formula that suits it best.

The outcome of health care reform in the United States will no doubt be very different from that in Britain, despite what some U.S. lobbying groups would have Americans believe. Britain's NHS lies at the opposite end of the spectrum from the current U.S. system, in terms of both its structure (a tax-funded public program as opposed to mainly private, employment-based insurance) and the problems it faces (historically, a lack of resources and slow uptake of new treatments as opposed to bulging costs), but in the late 1990s Britain had to confront reform on a scale as challenging as that being contemplated in the United States today.

In 1997, Britain had a new government, which had inherited a health care system that was chronically underfunded and suffering from a lack of capacity, with average waiting times of 18 months from referral to treatment. Funding for 1997 was £35 billion; for 2010 it is £110 billion, and waiting times are now as short as they've ever been — 10 years ago, patients waited approximately 18 months for treatment, and now they wait only a few weeks. Although both the causes of and responses to reform were very different from those in the United States today, the NHS's experience can provide some valuable lessons.

A key insight to be gained from the post-1997 NHS "revolution" is that it is important for clinicians to be involved in both informing and leading change. Successive attempts at top-down regulation and reform in Britain damaged clinicians' morale and bred distrust between them and politicians. Not having been central to the decision making, clinicians subsequently didn't trust the proposals or fully understand their purpose.

Last year saw the publication of the report High Quality Care for All, of which I, as a health minister, was lead author. Based on the findings of the Next Stage Review conducted by 2000 clinicians from all fields of care, it redefined the NHS, setting out a bold 10-year vision rooted in evidence of what matters to patients, the public, and NHS staff members. It established the mission of providing high-quality care — driven by clinical leadership, best evidence, and innovation — as the organizing principle of the service and has put the NHS firmly on the path toward systemic improvement in outcomes and efficiency.

Similarly, placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be the ambition of any new structure in the United States. Such an approach will lead to a health care system that has a democratic mandate and clinical leadership.

U.S. clinicians should bear three things in mind as they consider how to approach this debate. First, politicians must be made to recognize the role of clinical leaders in shaping a transformed but effective health care system. If clinicians can redefine the debate so that it focuses first and foremost on patients and health outcomes, that will provide a strong common purpose for efforts to tackle the challenges of funding structures and access to care.

Second, clinicians need to be involved in defining the link between funding and the care provided. It is for the patients at greatest risk that the U.S. system has the greatest difficulty providing access. The United States needs to find a model that best meets its needs while also being socially acceptable. Clinicians will have to find a brave voice if funding structures are to be reviewed in a way that puts quality of care before financial gain.

Finally, clinicians must educate both policymakers and the wider public about appropriate levels of care. Health care systems all suffer from a disproportionately heavy focus on the treatment of acute illness and injury — the type of medical work glamorized on television — which consumes by far the most resources. But primary care accounts for most of the health care that is delivered: nearly a billion visits are made to physicians' offices every year in the United States, but there are fewer than 40 million hospital stays. The current system of insurance and referrals can often lead to the unintended consequence of unnecessary referrals for the most expensive tests and treatments. Health problems related to lifestyle, such as obesity, smoking, and diabetes will be solved not by high-tech robotics and bigger hospitals but rather through access to family doctors, innovations in public health, and lessons from the emerging discipline of behavioral economics.

The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Britain's experiences to date, both good and bad, have proved this to be true. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.

Beveridge's characterization of revolutionary moments echoes in our ears today as the NHS goes through a period of radical reform. And as the United States, for its part, does what it does best — summoning up its revolutionary spirit — clinicians should step up and shape the debate, not wait to be handed a possibly misguided reform as a fait accompli.

No potential conflict of interest relevant to this article was reported.


Source Information

From the Health Ministry, U.K. Department of Health, and Imperial College — both in London.