December 3, 2009
Public Option: Great Britain's Warning to AmericaBy Linda Halderman, MD
Perhaps the most publicized, least understood aspect of the over 2,000 page, $850 billion health care reform bill being debated now in the U.S. Senate is the "public option."
Former Governor Howard Dean asserted last week at Yale University that without the public option, "this bill is worthless and should be defeated." Senate Majority Leader Harry Reid is pushing for a Senate vote by Christmas.
In arguing the merits and failings of a nationalized, government-sponsored health coverage program, there is an example of such a system Americans may wish to examine.
The United Kingdom delivers health care to citizens of its four member nations through its own public option, the National Health Service.
The National Health Service -- the UK's public option
Created in 1948 to provide universal coverage across the United Kingdom, the 60-year-old National Health Service (NHS) is a source of pride for many British nationals. For others, the utopian promise of government-sponsored universal healthcare has been a failure... or met at too high a price.
The UK consists of a multi-tiered system of public coverage that varies dramatically between the four nations served: England, Scotland, Wales and Northern Ireland.
In an attempt to address long wait times for English patients, the English system initiated a change in 2000 called "devolution." This allowed private hospitals to compete with state hospitals, decreasing wait times in England compared with sick residents of nations that forbid the involvement of the private sector.
Without the devolved system, those in Scotland, Wales and Northern Ireland willing to pay for faster care (such as cataract and hip replacement surgery as allowed in England using "Independent Sector Treatment Centres") are prevented from doing so by law.
But England's decrease in waiting times is relative. Prior to the introduction of competition via the NHS's devolution plan in 2000, wait times for a U.K. patient to be seen by a physician commonly exceeded two years. As of January 2008, the British government declared that its goal was to have all patients seen within 18 weeks of seeking medical care.
As many as 100,000 operations are canceled annually by the NHS due to shortages of facilities, doctors and resources.
England's four-month waiting period is a laudable goal compared with the Scottish system in which a waiting list reduction to six months is lauded by some as a measure of success.
In Wales, the waiting list target is eight months. Unfortunately for the country's residents facing acute and chronic illness, as of 2008 there were an additional 60,000 Welsh patients on the NHS waiting list than in 2001. A bright spot, according to Welsh leadership, is that the government health system provided free prescriptions for those who actually made it past the waiting list to be seen by a doctor.
For "non-critical" services like physical therapy and podiatry in Northern Ireland, wait times continue to exceed two years. Of the nation's 1.7 million residents, over 140,000 are on a waiting list to either be seen by a doctor for the first time or for a non-emergency hospital admission. These 2007 figures, according to Northern Ireland's Department of Health, Social Services and Public Safety, exclude patients whose visits and hospital stays were "deferred" or who missed an appointment. Such patients are counted statistically as "Completed Waits."
The United Kingdom's public option, faced with skyrocketing healthcare costs and under budget pressure, decreases costs by rationing care.
Each year, 9,000 British patients are denied kidney dialysis. An additional 15,000 are refused coverage for chemotherapy, and 17,000 are denied heart surgery.
Public option cost savings: patients become their own doctors
In early 2008, the NHS announced a plan to save "billions of pounds" that the British Department of Health proclaimed an "exciting opportunity" to address government healthcare spending that has doubled since 1997.
Prime Minister Gordon Brown agreed, lauding the new guidelines that curb healthcare spending in a way that supposedly aims to increase patient choice.
The "self-care agenda" encourages patients with chronic illness to monitor their own heart and lung functions with equipment installed in their homes. They could then report such information to their doctors by telephone, avoiding office visits and being seen by an actual physician. To further decrease the use of the National Health Service, patients would administer and monitor their own medications, doing self-assessments on the change in their condition rather than involving a physician or nurse.
Under the guise of "allowing [patients] to play a far more active role in managing their own condition," Prime Minister Brown promised that the new policy would simply increase choice for patients under the country's public option.
However, the Daily Telegraph cited an internal British Government document that revealed that the measures were actually about cost-containment and a reduction in expenses related to the care of elderly and debilitated patients served by the NHS.
After years of record spending increases, the NHS faces sharp Department of Treasury cutback demands to be met within three years. The "efficiency savings" require a reduction in NHS healthcare expenditures equivalent to over $16 Billion.
NHS advisors in the central government will establish guidelines for the "self-care" of patients. The stated goal is a reduction in NHS use by 14 million British citizens with chronic diseases like arthritis, asthma, diabetes and heart failure. Services expected to decrease under the new policies include primary care office visits, consultations with specialists, emergency care and prescriptions.
The public option and comparative effectiveness
There are consequences beyond long wait times of a health care system that removes decision making from the exam room and gives it to a central government.
In the U.K., health technology assessments are made by the National Institute for Health and Clinical Excellence (NICE).
In 2007, Swedish researchers reported in the Annals of Oncology that newer, more effective cancer drugs are less available in some European countries, including Great Britain, than other parts of the world.
The medical journal article explained how "research rationing" plays a role in the availability of cancer treatment:
"It was the explicit objective at the establishment of NICE to avoid any significant delays to bringing innovations to market in the U.K. There is yet no evidence that this objective is met."
Privacy under the public option
Equally concerning is the treatment of patient privacy; under the British system, the NHS is responsible for safeguarding medical records.
In December 2007, because of a civil servant's error, computer disks with personal information on half the British population -- including birth dates, addresses, national insurance numbers and bank account numbers -- were lost. The data was not encrypted, leading Treasury officials to call the security breach "catastrophic."
Prime Minister Gordon Brown told the House of Commons: "I profoundly regret and apologize for the inconvenience and worries that have been caused to millions of families," referring to fraudulent emails circulating that cite the data loss and invite recipients to "confirm" their "security details."
The lost records involved nearly all British families with children, whose NHS payments are often routed directly into bank accounts.
This was the third security breach for the country's public option in five months. Nevertheless, plans for a national medical-records database and biometric identity cards for all covered citizens are going forward.
Guy Hosein of the watchdog group Privacy International: "It's impossible to control this much data.... Whenever you collect information and keep it centrally, it will be...lost."
Primarily because of privacy concerns, two-thirds of family physicians in England plan to boycott the government's attempt to create a database of 50 million National Health Service patients' electronic health records. Nearly 60% of Primary Care physicians are unwilling to upload any record without the patient's specific consent.
The NHS procurement agency for information technology (IT) is attempting to persuade doctors that a "summary health record" on a £12.4 billion NHS-controlled electronic database would save lives.
The British Medical Association: "The government will not regain the confidence of the public or the profession unless it can demonstrate that its systems are safe."
The future of the British public option: market reforms
The failures of the NHS, including a recent Department of Health admission that one in eight patients wait more than a year for needed surgical procedures, have led to a shift away from the public option toward market reforms.
The socialist Labour Party once scorned private medicine, dismissing it as "Americanization." But now Labour promises to triple the number of private sector surgical procedures provided within two years, and recently considered contracting some primary care services to American companies.
Dr. Linda Halderman is a general surgeon and policy advisor in the California State Senate. Since the September 29, 2009 earthquake and tsunami that devastated the South Pacific, she has been providing medical relief on American Samoa.