To those who admire the NHS: Empower primary care physicians

A recent report from the Commonwealth Fund, which placed U.S. last amongst developing nations in health care, analyzed Britain’s high score on the management of chronic conditions. The authors attributed care coordination to the widespread adoption of health information technology in the National Health Service (NHS).

That’s like someone saying Chinese food is tasty because chopsticks are widely used.

Like quants so fastidious about decimal points they’ve missed the overall point.

Where do I begin?

I’ll start with Mesozoic era, before health IT was thrust upon Britain’s general practitioners (GPs). Then you had GPs and specialists. In Britain, GPs are not optional. Everyone needs to be registered with a GP. OK, you don’t get fined if you don’t have one, but if you want a referral to a cardiologist you need to see your GP which means you must have one to see in the first place.

Read my lips: no GP, no cardiologist.

If your cardiologist thinks there’s nothing wrong with your heart and your problems are supratentorial for which you need to see a psychiatrist, then he must write a letter to your GP asking that he might consider referring you to the psychiatrist. A specialist can’t refer to another specialist, bypassing GPs.

The result is that GPs know their patients. They know the genuinely ill. They know those who, adept at web searching “dizziness,” end up with a diagnosis of pheochromocytoma of the bladder from Dr. Google.

Let me state this differently. Every patient has one doctor who knows everything of medical relevance about them (nearly).

How were these paleolithic GPs communicating before electronic medical records?

Pigeons? Telegraph? Morse code? Smoke from chimneys?

No, it was a quaint thing called a referral letter. You know the ones that start off with:

Dear Dr. Singh,

Many thanks for seeing this delightful 68-year-old lady of Indian origin who is somewhat active for her age, but has recent deterioration in exercise tolerance. I have reduced the dose of her daily atenolol. She is not anemic.

Then Dr. Singh would reply:

Dear Dr. Smith,

Thank you for referring Mrs. Patel, a delightful 68-year-old lady who was accompanied by her concerned daughter-in-law, a Cambridge-educated barrister. The reduction in atenolol has restored her to baseline physical activity. I was happy to report to her that the electrocardiogram and chest x-ray you so kindly arranged were normal. No further investigations are necessary but I have requested an echocardiogram, to reassure her Cambridge-educated daughter-in-law.


Dr. Maninder Singh, FRCP (Manny)

P.S.: I haven’t seen you on the golf course recently.

Dr. Smith is forewarned of Mrs. Patel’s aggressive daughter-in-law. Mrs. Patel remains delightful, and well managed. More importantly, both providers are in the know.

There’s a name for this. It’s called “communication.”

It doesn’t require schools of clever programmers, reams of codes, scores of entrepreneurs and mountains of subsidies from big government. It arises partly because of culture and partly from necessity.

It arises when GPs must be sovereign in their knowledge about the patient. When GPs are the masters of primary care and the drivers of secondary care. When GPs are care givers, care coordinators and care chroniclers. That’s a lot of responsibility.

Is such a system restrictive?

Of course it is. Imagine you have a headache. You see a billboard on I-95 of a clever neurologist working in a center of excellence. How inconvenient must it be to have to go through a primary care physician (PCP) and not exercise your constitutional right to see a specialist directly?

Britain doesn’t have these problems. Partly because they don’t have billboards of physicians on freeways. But mostly, I dare say, it’s because they know that with universal health care comes compromise.

Britain’s GPs are battle-hardened. They often deal with soaring demands that exceed the resources of the health care system.

My friend, a GP, had this conversation with a patient.

Patient: “I need a heart CT scan.”

GP: “Perhaps. But first you must tell me what’s wrong with you.”

Patient: “I have chest pain.”

GP: “Can you point to where you feel the pain?”

Patient: “I just told you! It’s in my chest. And I need a CT scan.”

GP: “Yes, but you must still point to where it hurts.”

Patient: “You’re a lousy doctor. I’ll write to the Daily Mail. If I die from heart attack it will be on your conscience.”

GP: “My receptionist will help you file the complaint. We also have the name of some GPs in the neighborhood, should you choose to change your GP.”

Patient stomped off. Patient complained. My friend wrote an apology letter that expressed “deep regret” and gratitude for “timely call to introspection about the greater values in society.” Thanks to health IT he has a cache of standardized letters which express varying degrees of regret. For this interaction he used the “mild regret” macro.

Nothing came of the complaint. He had documented the conversation.

Can American PCPs ignore a patient’s demand for medical imaging? What, with all the Press Ganey scores, defunct quality metrics and consumer-centric stuff? What, with another PCP ready to steal the consumer? What, with all the lawyers waiting to pounce on that statistically-inevitable bad outcome?

My friend is not terribly concerned about Britain’s scarce resources or population health. Or that Orwellian term “resource stewardship.”

“If I acquiesce to her demand for CT scan I’ll have to say yes to everyone. And we’re not like the U.S. We don’t have CT scans in shopping centers. We have to triage and think about clinical necessity,” my friend reflects seriously.

Britain’s GPs, indeed all physicians and patients, are constrained in their utilization by the constrained resources of the system. U.S. policy makers want U.S. physicians to constrain their utilization to constrain the presently abundant resources and without compromising anything, least of all consumer satisfaction. That’s a big difference. It’s the difference between passive diffusion and active transport.

I digress. But not that far. For care coordination health IT is neither necessary nor sufficient. You need a provider charged with overall responsibility for the patient, who can be bypassed by neither the patient nor the specialist. The provider will have responsibility. And therefore power. Including the power to ignore the patient’s demands without repercussions. Otherwise the system will collapse.

In Britain that provider is the GP. In the U.S., the PCPs are more than capable of taking on the role. But the system will punish them for trying. Because politicians are not willing to put their Press Ganey scores where their mouths are. Because we seek in health care reform a fairy tale NHS, ceteris paribus.

The report places Britain at number 1. Yet I doubt that many Americans, even the self-proclaimed NHS-philes, could abide Britain’s NHS for a day. Not if it interferes with that sacred cow “choice.”

The report is prescriptively useless for all, particularly fossil fuel billionaire Sheikh Abdullah from Bahrain seeking treatment for cancer, who is still likely to visit MD Anderson for treatment rather than a district general hospital in Britain’s NHS where they still write quaint referral letters.

“Yes, but high intensity of medical treatment doesn’t improve national outcomes,” a clever health economist will solemnly warn the Sheikh. “Choose Switzerland. Choose Norway. But stay away from the U.S.”

“Yes, but what do I care about populations,” the sheikh will rejoin. “It is I with the cancer, not the Republic of Bahrain.”

Such is health care, and those that measure it, and those that use it. A mind-boggling paradox.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad.

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