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The crisis in American health care has led to interest in other national health systems, with the Canadian and German systems most often cited as models for U.S. reform. These discussions usually overlook the British National Health Service (NHS). To many U.S. observers, the NHS bears the stigma of "socialized medicine," with images of excessive government controls, inadequate resources, and salaried physicians with low incomes4. Yet the U.K. system scored highest in a recent 10-nation study of primary care5. Many long-established features of the British approach to health care organization and payment, such as a strict system of referral to specialists, a mixture of capitation and fee-for-service reimbursement, and responsibilities for defined populations in the community, are being introduced in managed-care plans in the United States -- usually with little cognizance of their British origins. More recently, market incentives for primary care practitioners introduced under the legislative reforms known as the New Contract for the NHS create even stronger resemblances between features of managed care in the NHS and the United States.
In this article, we shall compare primary care in the United States and the United Kingdom, emphasizing similarities as well as differences in the overall health care systems and in the structure, processes, and outcomes of primary care in the two nations.
System
Primary care is not an island, but part of an overall system of health care6. In the United Kingdom the enactment of universal coverage under the NHS in 1948 supplanted a selective national health insurance system for low-income workers devised before World War II. All residents are entitled to comprehensive medical care from the NHS that is free at the point of service. There are minimal copayments for drugs, eyeglasses, and dental services for adults. Approximately 10 percent of the population also has supplementary private insurance for specialists' services and hospital services (but not for primary care). Table 1 compares health care expenditures, health care coverage, and vital statistics in the United Kingdom and the United States.
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In any system there are four recognizable levels of care: self-care, primary care, care by a general specialist, and care by a subspecialist. In a system guided by explicit planning, such as the NHS, the boundaries between the levels are distinct and each level of care corresponds to specific administrative units and population sizes.
Self-care is often unappreciated by physicians but represents the type of care provided for 80 percent of all symptoms12. When a person decides to seek the care of a professional, that professional provides the initial primary care, whether he or she is a generalist or specialist physician or a nonphysician professional. In the United Kingdom, the general practitioner serves as primary care physician. All persons in the United Kingdom are entitled to register with a general practitioner of their choice and may change that registration at any time. Although there are no formal restrictions on the choice of a general practitioner, most people elect to register with a local general practitioner.
General practitioners are independent contractors with the NHS (not salaried employees), providing all necessary comprehensive and continuing general medical services to their registered patients on a 24-hour basis. The general practitioner is also responsible for coordinating local hospital and community services. In the United Kingdom, the ratio of general practitioners to the general population is 1 to 175813.
When a general practitioner decides that advice or treatment from a specialist is necessary, the patient is referred to a general specialist, such as a surgeon, obstetrician-gynecologist, or internist. In complex situations the help of a subspecialist may be required. In the United Kingdom, general specialists work at district hospitals serving a population base of 100,000 to 500,000 and subspecialists are located at regional tertiary care hospitals serving a population of 500,000 to 5,000,000.
A strict referral system governs the flow between levels of care in the United Kingdom. There is a single portal of entry to the NHS -- namely, the general practitioner gatekeeper, who is responsible for referring patients to a specialist. Patients cannot refer themselves directly to a specialist.
In the United States, the structure and flow of care are more complicated and varied, and the borders between primary care physicians and specialist physicians more blurred than in the United Kingdom. Whereas general practitioners provide virtually all primary care services in the United Kingdom, with internists and pediatricians serving mainly as hospital-based consultants, in the United States family physicians, general practitioners, general internists, and general pediatricians all share in the provision of ambulatory primary care. Moreover, many physicians in specialty and subspecialty fields, such as obstetrics and gynecology, cardiology, and general surgery, also serve as principal physicians providing general care to their patients14. The term "specialoids" has been used to describe physicians trained to be specialists, but who exist in abundance relative to the supply of patients with the special problems that are required to support an exclusively specialized practice6. Much initial care in the United States also occurs in emergency departments and free-standing urgent care centers15.
Traditionally, insured patients in the United States have been able to enter the system directly at any level of care, rather than routing their needs through a single primary care portal of entry. Indeed, the patient with a dermatologist caring for her eczema, a cardiologist treating her essential hypertension, a gastroenterologist tending to her chronic dyspepsia, and a gynecologist performing a Pap test each year has become almost a caricature of the American health care consumer. This pattern of multispecialty care is waning, however, as more and more health plans adopt a British-like policy of primary care gatekeepers. Many managed-care plans now obligate patients to select a primary care generalist for continuity and coordination of care, with referral from the primary care practitioner required for the use of specialists' services16.
In the United Kingdom, the explicit relation of a general practitioner's practice to a designated group of enrollees makes a population-based orientation to health care possible. Recent changes in the NHS contract have codified this population-based accountability of the general practitioner by linking reimbursement for certain services such as Pap tests and childhood immunization to achieving specified target levels of screening. These targets are set with the total eligible population registered with the general practitioner's practice as the denominator (e.g., women or preschool children), rather than simply the patients who have had regular contact with the physician. In the United States, attempts to promote a similar model of community-oriented primary care have frequently been stymied by the lack of a clear relation between a designated community-based population and individual primary care physicians17. Large staff-model and group-model health maintenance organizations (HMOs) offer the potential for a more population-based model of health care in the United States, although these HMOs have not uniformly engaged in community outreach to enrolled populations or implemented other features of community-oriented primary care.
In the United States in 1990, the ratio of office-based primary physicians (family practitioners, general internists, and general pediatricians) to the general population was 1 to 176918. Group-model and staff-model HMOs with more than 100,000 enrollees have approximately one primary care physician per 1000 enrollees19. Despite the anxiety over the low numbers of young physicians entering primary care practice in the United States, the ratio of primary care physicians to the general population is almost identical to that in the United Kingdom. The problem of physician supply in the United States may lie more in the relative distribution of generalists and specialists than in an absolute deficiency of primary care physicians3,20. In addition, geographic maldistribution of primary care physicians persists in the United States. In the United Kingdom, explicit policies of physician allocation have eliminated undersupply to rural and inner-city areas.
Because the British government acts as the single payer for undergraduate and postgraduate medical training, as well as for reimbursing practicing physicians, regulatory authority over the total supply of physicians, specialty mix, and geographic distribution is consolidated in the national departments of Education and Health. Medical education is free, and half of all new medical graduates willingly opt for general practice as their first choice. In the United States there are few controls over medical school and residency positions. Primary care residency programs are underfilled as compared with subspecialty programs, and students graduate with high levels of indebtedness1.
Reimbursement
The NHS reimburses general practitioners through a combination of methods. Sixty percent of payment is in the form of capitation reimbursement for every patient registered with the practice. In addition, the NHS pays on a fee-for-service basis for special services such as nighttime home visits and specific health-promotional services, such as immunizations, Pap tests, and regular checkups for the elderly. The NHS also subsidizes practice overhead through block grants that pay the full cost of office space and property taxes and 70 percent of salaries for office staff members. Fee levels are set annually by an independent quasi-governmental Doctors' and Dentists' Pay Review Board. General practitioners are entitled to six weeks of paid vacation each year, as well as paid sabbatical leaves. They also receive pensions from the NHS on retirement, which is compulsory at the age of 70. Unlike general practitioners, specialists in the United Kingdom work as salaried physicians and are based at hospitals.
The reimbursement of primary care physicians in the United States is considerably more complicated and administratively cumbersome. Often, an office-based primary care physician must juggle a mix of payment arrangements for each patient depending on the type of insurance coverage (if any). Some patients may belong to plans paying capitation fees to a primary care gatekeeper, others may be covered by plans paying according to a discounted fee schedule, and others may belong to plans that reimburse on the basis of charges21. Deductibles, copayments, heterogeneous benefit packages, and patients without coverage further complicate the process of reimbursement for primary care services in the United States.
American physicians participating in capitation contracts with HMOs usually assume a much greater financial risk than do British general practitioners working under capitation arrangements with the NHS. Traditionally, capitation payments in the NHS cover only services provided by the general practitioners themselves; the NHS uses different funds to pay for such things as consultations with specialists, laboratory tests, and medications. In the United States, primary care physicians working under capitation contracts must almost always pay for consultations with specialists and laboratory and radiographic studies out of the primary care capitation fund. Many contracts require payment for prescription drugs and various other supplies and ancillary services from the capitation fund as well22. The greater financial risk borne by American physicians reflects in part the absence of the supply restraints that limit the overall capacity of the NHS for technology- or specialist-dependent services and procedures.
Under the New Contract ushered through Parliament in 1991, payments to general practitioners may soon more closely resemble American contracts drafted in the style of the independent practice association. All general practitioners are now subject to a financial cap on expenditures for prescription drugs. In addition, group practices with 9000 or more enrollees may opt for a broadened capitation primary care budget. Similar to the arrangements for many American gatekeepers, general practitioners can assume the responsibility (and liability) for paying for diagnostic tests, consultations with specialists, and surgery from this primary care budget. One important difference between these financial incentives in the two nations will remain: British general practitioners must reinvest any profits from surpluses in their primary care budget into practice improvements; the profits cannot be retained as additional net income23.
Table 2 compares the annual incomes of British general practitioners and family and general internist physicians in the United States. Practice expenses were much higher in the United States: 57 percent of gross income, as compared with 33 percent in the United Kingdom.
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The services that a good program of primary care should provide include initial assessment, diagnosis, and management; long-term continuous comprehensive care of people and their families; health promotion for a defined local population; and coordination of specialists' and community services5,6. The primary care physician should act as a personal physician, philosopher, and friend; a guide through the medical jungle; and a protector of the patient from inappropriate visits to specialists and of specialists from inappropriate referrals of patients16. The following sections compare the ways in which these primary care services are delivered in terms of who does what and where, when, how, and why things are done.
Who?
In the United Kingdom, the past decade has seen the advancement of the health team, with groups of general practitioners working at common premises in the community in collaboration with nurses, public health nurses, midwives, social workers, receptionists, and secretaries. This trend was initiated and maintained through government policies adopted in 1965 to subsidize the expense of office staff for general practitioners directly, rather than leave general practitioners to employ staff out of their capitation funds. In addition to the on-site staff, each practice collaborates closely with "attached" staff, such as home nurses, public health nurses, midwives, and social workers, employed directly by the NHS. The team is structured to take on the challenges of outreach and community-oriented primary care. For example, home visitors help the frail elderly live independently in the community. Practice nurses conduct various educational and health-promotional group clinics, such as those teaching patients with chronic diseases to care for themselves and those teaching smoking-cessation techniques. Such fully integrated teams are less common in the United States. Much of the office staff's time in the United States is consumed by billing and other administrative procedures26.
At the same time that policies were introduced in the United Kindgom in the 1960s to promote interdisciplinary teamwork, the NHS also implemented financial inducements for general practitioners to work in groups, offering larger practice subsidies to groups of three or more physicians. Whereas in 1960, more than one third of all general practitioners worked alone, now only 1 in 10 do so, and 42 percent work in groups of 5 or more (there are no multispecialty groups in the United Kingdom)13. In the United States, 40 percent of family physicians still work solo27.
What?
The average primary care practice serves approximately 2000 persons. About 55 percent of consultations are for minor, benign, and often self-limiting conditions, 30 percent for chronic disorders, and 15 percent for more acute, major, and potentially life-threatening diseases13. In both the United Kingdom and the United States, the majority of office visits to general practitioners and family physicians are for respiratory tract infections, hypertension, ischemic heart disease, minor trauma, arthritis, diabetes, and anxiety or depression28,29.
Where and When?
The work of primary care is performed in many places. Table 3 compares a typical week's volume of consultations and hours of work by a British general practitioner and a U.S. family physician. Although the total numbers are similar, the British general practitioner still makes many home visits but has no hospital privileges. The U.S. family physician makes almost no home visits but provides hospital care. The U.S. physician works more hours per week.
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In the United States, a family physician spends an average of 12 minutes with a patient during an office consultation27. In the United Kingdom, a physician spends eight minutes with a patient13. Family physicians in the United States make greater use of laboratory, radiographic, and other diagnostic tests in their own offices. In the United Kingdom, general practitioners carry out only basic tests in the office and refer patients (or send samples) to diagnostic departments at local hospitals. There is no direct access by general practitioners to high-technology procedures such as magnetic resonance imaging and echocardiography. A comparison of practice patterns among general internists in the United States and general practitioners in the United Kingdom for patients with uncomplicated hypertension found that the U.S. internists ordered 40 times more electrocardiograms, 7 times more chest films, 5 times more blood counts, and 4 times more urinalyses than the British general practitioners30.
In both the United Kingdom and the United States, fewer than 1 in 10 consultations with a primary care physician result in referral to a specialist. A prescription for medication is issued in 60 percent of consultations with general practitioners in the United Kingdom and in 71 percent of visits to family physicians in the United States (Table 4)27.
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There are remarkably few data on health outcomes and the quality of care that would permit meaningful comparisons of variations in practice patterns and in the organization and reimbursement of primary care services within nations, much less across different systems32. Although the single-payer structure of the NHS offers the potential of an integrated data base for monitoring patterns of practice and outcomes, this data base has yet to be well developed.
Comparisons of the cost effectiveness of primary care in the United Kingdom and the United States tend to rely on relatively crude statistics. Health indexes are very similar in the two nations (Table 1). Per capita costs are the main difference, being three times as great in the United States as in the United Kingdom. With similar outcomes it is fair to ask, What are the extra benefits, and for whom are they meant?
Discussion
The importance of primary care is well recognized in the United Kingdom, where general practitioners and the primary care team have a critical role in the NHS. In the United States, primary care has been relatively unappreciated and undervalued in a system that rewards specialization and technology-oriented care. The lack of organization and planning in the U.S. system as a whole is reflected in the blurred distinctions between generalists and specialists, the absence of clear responsibility for population-based health care, the uneven flow of patients through the system, complicated and often incomplete remuneration, and the paucity of group practice and interdisciplinary teamwork. Calls for the rejuvenation of primary care are coming from a number of quarters in the United States33,34.
One factor influencing the future of primary care in the United States is the so-called managed-care revolution. Many features of primary care in the United Kingdom are surfacing as themes of managed care. Most managed-care plans rely on generalist physicians to serve as gatekeepers. As in the United Kingdom, managed-care plans are experimenting with capitation as an alternative to fee-for-service reimbursement. Large, vertically integrated HMOs may have structures conducive to practicing population-based medicine and fostering group practice among different types of health care professionals. Yet these shared features of primary care in the NHS and U.S. HMOs are colored by their very different contexts: a government-administered single-payer system providing universal coverage in the United Kingdom and a competitive, multipayer system with large gaps and frequent changes in coverage in the United States. In the United States, realization of such primary care principles as continuity of care and unimpeded access to primary care physicians will almost certainly require a more stable and universal system of health insurance with greater public oversight and accountability.
Despite these differences, the clinical content of primary care is remarkably similar in the two nations. The British general practitioner and the American family physician care for patients with the same common ailments and conditions and prescribe similar types of remedies.
Many questions remain unanswered. Does the fact that the ratio of primary care physicians to the general population is the same in the United States and the United Kingdom (approximately 1:1750) mean that the current supply of primary care physicians is adequate in the United States, or is the 1:1000 ratio found in the large HMOs a more appropriate target for the overall U.S. system? Are procedures and processes less effective and efficient in the United States, with less teamwork and shared care? Is a 12-minute primary care visit in the United States better than an 8-minute visit in the United Kingdom? Do patients' expectations differ in the two nations? Does the different stature of primary care in the United Kingdom and the United States partly explain why per capita costs in the United States are three times those in the United Kingdom?
With so many issues and questions to answer, it is surely necessary for joint cross-national thinking, planning, and sharing of experiences to produce some basic models of excellence.
Source Information
From the Department of Family and Community Medicine and the Institute for Health Policy Studies, University of California, San Francisco, San Francisco (K.G.), and Beckenham, United Kingdom (J.F.).
Address reprint requests to Dr. Grumbach at the Institute for Health Policy Studies, 1388 Sutter St., 11th Fl., San Francisco, CA 94109.
References
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