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A glimpse of a US-style future

They say that what America does today, Britain will do tomorrow. I’ve spent the last nine months working at a huge and prestigious American department of medicine. I have seen the future, and it doesn’t work.

While I’ve been trying to write a book about Patient Centered (sic) Medicine at Yale, I’ve tried not to think about what’s happening to you back home. I remember when the Americanization of the NHS began to be talked about in the mid-1980s.The purchaser/provider divide arrived in the early 90s, and it’s been the bane of properly coordinated care ever since. But we’ve lived with it, as we live with everything else that fate throws at British general practice. The political rhetoric of choice and competition will always be a bit of a joke to most GPs, who have the choice of one local hospital and the people who work there. Now we’ll be expected to shop around with an ever-decreasing budget.

In the USA, most GPs (if they existed) would have several hospitals and an oversupply of competing doctors for sick patients to choose from. Or maybe not. Patterns of provision vary wildly, based on a variety of feedback loops which usually work in the direction of unrestricted overprovision. Jack Wennberg discovered the phenomenon of small area variation and supply-led demand in the US health system in the early 1970s. There seems to be no way of stopping it. So four decades later, the USA health system is crammed with competing medical facilities and has reached the point of unaffordability, while its performance judged by crude measures such as life expectancy and infant mortality is amongst the worst in the rich world. I spoke to Jack this week and he is baffled how anyone can think that choice and competition can drive up standards of care and drive down costs. The opposite is true.

You’d imagine that American teaching hospitals provide the best care in the world, if only for those fortunate enough to get access to it. But the care I have observed on ward rounds is often a combination of frenetic over-investigation combined with an unseemly hurry to get patients discharged. I have even heard this from doctors who have had serious illness: they have had to struggle to co-ordinate their own care.

Half the tweets I’ve followed in the last week announce the death of the NHS. But I don’t think the NHS can really die, despite the worst efforts of politicians. It is a tough call, but if GPs are willing to share real power with patients, we can rebuild the NHS in partnership with them. Trust patients to tell you what services they want and how they have experienced them. Demand kindness as well as cost-efficiency from the services you provide and those you commission. Share decision-making with those who want it: carry the burden for those who cannot. Take pride in being a professional. Markets will never care much about the ill and needy, but we can show society that there are other values.

Dr Richard Lehman is a retired GP from Oxfordshire. He is currently spending a year after retirement working at Yale on projects to do with open access to research data and what patient-centred care might really mean.