The National Health Service (NHS) in the United Kingdom is sometimes demonized in sections of the American media, particularly in the run up to presidential elections. The threat of rationing, long waiting times, and “death committees” permeate the debate, with those opposed to socialized medicine doing the shroud waving, and trying to frighten the electorate and derail any movement of American healthcare toward an NHS-style system. I recently had the honor of visiting a leading academic and clinical center in the U.S. It was a pleasure to compare U.K. with U.S. rheumatology. I have chosen not to name the center, as some of my comments may be read as critical, which they are certainly not meant to be. They are simply the reflections of an outsider looking in, from the perspective of a different healthcare system. The U.K. NHS is undergoing yet another round of enormous change, with the emphasis of the government being on increasing value in healthcare (with “value” defined as outcomes divided by resources spent). In transforming the NHS, there is much that can be learned from other healthcare systems, both in terms of what should be emulated and what might be avoided!
The U.K. and U.S. have major differences in healthcare provision. It might surprise my American colleagues to hear that after having had long conversations with esteemed U.S. colleagues, I would rather work in the U.K. NHS than in the American healthcare system. Perhaps this is familiarity, but I do think that a national socialized medical system has significant advantages over the often-fragmented and unequally distributed U.S. system. Let me try to describe U.K. rheumatology for my American colleagues, and see if I can justify my preference.
1. New patients do not have direct access to me. I am currently not allowed to advertise my services, although my contact details and patterns of work are made available to general practitioners (GPs—our primary care physicians). The majority of my referrals come from GPs. They can judge how urgent the referral appointment needs to be. This results in a high proportion of my referrals being relevant to my clinical knowledge and skills. However, this system occasionally leads to delays in referrals, and some GPs are better than others at judging whether a referral needs to be made and how speedily, though with ongoing education of, and interaction with, GPs, we seek to minimize this delay. For urgent referrals, we provide an on-call service so that patients can be seen the same day. For early inflammatory arthritis patients, we have a booking system that gets patients into clinic within two weeks of referral. Other patients do not have to wait more than six weeks for an appointment, which is a lot longer than many U.S. patients—providing, of course, they have the insurance or funding to access a rheumatologist at all.
2. I do not have to check the insurance details or ability of the patient to pay. No money or credit card details are exchanged. This speeds up my clinic and administrative time so that I can concentrate on the clinical problems of the patient. It decreases the costs of providing healthcare, with far fewer administrative staff than are employed in the U.S. I do not have to get clearance from any third party before organizing investigations or prescribing medications (with the exception of NICE guidelines, covered below).
3. I work with other rheumatologist colleagues and a multidisciplinary team to whom I can rapidly refer appropriate patients. We have developed pathways within the department based on national evidence-based guidelines and local consensus. This decreases variation in practice among colleagues, which can be wasteful of resources. This managed approach is likely to be intensified, with the current government keen to introduce commissioning of services, specifying what services should include and which outcomes should be measured and achieved. This strategy may improve the value of healthcare, emulating some of the managed healthcare systems in the U.S. Some models of commissioning may include a budget for biologics, encouraging rheumatologists to see inflammatory arthritis patients quickly, and make best use of short-term steroid therapy and combinations of conventional disease-modifying antirheumatic drugs (DMARDs) before considering the use of biologics. Decreasing the need for just a few patients to be treated with biologics could release resources to be invested in other important aspects of multidisciplinary care.
4. In 1999, the Labour-led government introduced the National Institute of Clinical Excellence, which has undergone a number of name changes since, but is still abbreviated to the acronym “NICE.” NICE was created to improve the quality of care through guidelines, and to decrease the variation in availability of drugs across the NHS, often referred to as “postcode prescribing.” NICE allows health ministers to distance themselves from difficult and unpopular decisions on access to medications by delegating responsibility to an independent body that could render decisions based on evidence and health economics. These decisions always create controversy, because health economics is not a pure science, and the answers that emerge from models depend on the quality of data and assumptions that are put into them. However, there are advantages of NICE technology appraisals, including:
- Acknowledging and accepting the existence of bias, its manifestations, and its effects;
- Leveling the playing field for all interventions and all diseases by using cost-effectiveness approaches;
- Providing legally binding access to eligible patients, enshrined in the NHS constitution;
- Use of transparent methodologies;
- Publication of all their considerations;
- Removing some of the decision making on eligibility for biologics from the individual clinician, thus decreasing variation in practice;
- Revisiting available evidence every three to four years, during which time it is incumbent on stakeholders to improve the evidence base if they want NICE to reach different conclusions; and
- Increasing flexibility to negotiate with drug companies over the price charged to the NHS to reflect the cost effectiveness of the drug.
The disadvantages of NICE are:
- It only takes into consideration the costs of the disease and drug to the NHS, and not broader socioeconomic costs (such as ability to stay in work or burden on carers, though this may be changing);
- It can be slow to reach conclusions;
- It has led to conclusions that make the U.K. look much more restrictive in allowing access to biologics than other developed countries. For example, for an RA patient to have access to a first biologic drug, they must have a DAS28 score greater than 5.1 on two occasions at least one month apart, and they must have failed to improve using two conventional DMARDs, with one usually being methotrexate. In my practice in Derby in the Midlands in England, I have 15% of my inflammatory arthritis patients being treated with biologics. This compares with around 50% of patients treated at the U.S. center of excellence that I visited. This may mean that I am not allowed to use enough biologics for the needs of my patients, or alternatively, my U.S. colleagues are using too much. It may be that I am forced to make more use of conventional therapies, or that I am making too much use of them and not putting patients onto biologic therapies who would gain more benefit from them than from conventional DMARD regimens. My U.S. colleagues appeared to make little, if any, use of short-term steroids, and if their patient failed on methotrexate monotherapy, there was a good chance they would move straight onto biologic drug therapy. If I behaved in the same way, I would be in breach of NICE guidelines, and local commissioners would not pay for the therapies.
As with all complex systems, I am sure that the best approach lies somewhere between our practices. I wish I had greater access to biologics for some of my patients where the NICE eligibility criteria appear unduly restrictive, but I also believe, particularly at a time of financial stringency, that my U.S. colleagues might make more use of conventional therapies. There is an increasing evidence base from a number of randomized controlled trials that intensive conventional therapy regimens can decrease the need to use biologics. In Derby, we have data showing less use of anti–tumor necrosis factor drugs over time, in part because we are increasingly seeing patients early and treating them intensively with conventional DMARDs. In financially restrictive times, the U.S. might learn from U.K. practice, as I would wish to incorporate some lessons learned from my American colleagues.
In conclusion, there are big differences in U.S. and U.K. rheumatology, with each having its own strengths and weaknesses. With commissioning of services and increasing involvement of private providers, the U.K. system may be moving more toward a U.S. style of healthcare. Ironically, with the passage of the Affordable Care Act, President Obama seems keen to move the U.S. system more toward an NHS system. Perhaps the best healthcare system lies somewhere in between!
Dr. Deighton is president of the British Society for Rheumatology and a consultant rheumatologist at Royal Derby Hospital, U.K.
