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The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org.
The United Kingdom takes the importance of primary care for granted. The U.K. government is effectively the country's single payer, and successive administrations have been convinced by mounting evidence that primary care promotes high-quality, cost-effective, and equitable health care.1 If anything, the U.K. government has become more convinced over the past 15 years that strong primary care needs to be at the heart of the country's health care system — quite the reverse of the situation in the United States. U.K. primary care physicians now have average earnings of $220,000 (in U.S. dollars), which is more than many specialists earn. The payment system is a mixture of risk-adjusted capitation and 25% additional pay for performance.
Having a single-payer system helps a great deal in terms of organizing quality-improvement activities. Over the past decade, the U.K. government has been able to introduce myriad nationwide quality-improvement initiatives, ranging from annual performance reviews of all physicians by local peers and national standards for the care of major diseases to coordinated local programs of clinical auditing. These activities have resulted in substantial quality gains2 so that the additional introduction of a major pay-for-performance scheme in 2004 resulted in only modest further improvement.3
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U.K. primary care physicians increasingly work in multidisciplinary teams, with nurses taking on an increasing proportion of the work. Nurses see patients with minor illnesses and assume responsibility for the routine management of chronic diseases. Physicians generally agree that it makes sense to hire nurses to provide protocol-driven care for chronic diseases. This model has now become universal for primary care in Britain, although there is some concern that the increasing use of nurses in specialized roles may result in physicians' becoming "deskilled."4
Having a single-payer system also means that U.K. primary care physicians hold each patient's lifelong record, which includes a letter regarding every visit to a specialist. Virtually all primary care physicians use electronic medical records, and laboratories now generally download lab results directly into family practitioners' computer systems. Again, the government took advantage of having a single-payer system to define common standards to which all suppliers of electronic medical records must adhere.
Some U.K. primary care physicians are concerned that they are losing the personal contact they used to have with patients. Many recognize that the very personal care long associated with the "family doctor" is becoming less common. To some extent this is because primary care physicians have increasingly focused on clinical quality indicators for major chronic diseases and work in larger teams with other physicians and nurses in an effort to perform well on those measures.4 If such a team becomes too large and the physician becomes too remote from the patient, however, other aspects of care may suffer. To redress this balance, the U.K. government is now starting to survey patients, and it plans to use the results to report publicly on continuity of care and the interpersonal qualities of physicians in all 8500 primary care practices in England.
U.K. primary care physicians gave up contractual responsibility for providing 24-hour care in 2004. Although this move was very popular with physicians, it may turn out to have done long-term harm to both physicians and patients. Most physicians were already organized into large groups for the provision of off-hours care, so the actual additional workload was small. Since the change, off-hours care has become much more fragmented. Patients sometimes receive poor service, and they have lost the sense they once had that their primary care physician was "always there for them" (even if, in reality, he or she rarely was).
It is hard to discuss U.K. medical care without mentioning universal coverage. Although it may not be politically achievable in the United States, universal access to care is probably the key factor behind findings that U.K. citizens have better health outcomes than their U.S. counterparts despite having health care costs that are a fraction of those in the United States.5
Although some features of U.K. health care would be hard to transplant to the United States, some that seem to work well in Britain have been advocated by U.S. experts on primary care — for example, registration with a primary care physician, payment involving a mix of risk-adjusted capitation and pay for performance, electronic medical records, and the use of extended teams to improve quality. Are these approaches beyond the realm of political possibility for U.S. health care?
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Roland is a professor of general practice and director of the National Primary Care Research and Development Centre, University of Manchester, Manchester, United Kingdom.
References
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