I am a huge fan of Britain’s National Health Service (NHS), but probably not for the reasons many people might assume. It’s not because it’s “socialist” (a horribly inaccurate description), or that it’s nationalized, or anything like that. I’m a huge fan because somehow the people of Britain have developed the courage to talk about healthcare using very adult language. In the U.S., we can rarely progress beyond the equivalent of screaming toddler fits.
The British economy took a larger hit from the recession of 2008-9 than much of the rest of the world. Irrational exuberance apparently crossed the Atlantic and took root in the London financial markets. The NHS has been under the reality of “austerity” ever since (read tax hikes and budget cuts). No one is happy about the situation, but they soldier on discussing their options and trying to continue to do what the U.S. can’t: deliver the best care possible living within the realities of fixed budgets.
That’s why the BMJ has articles that use the word “rationing” in them, as do some newspaper articles in the mainstream press. The NHS is rejecting requests for hip and knee replacement surgeries that are deemed to be more marginally indicated, as well as procedures deemed to be ineffective (such as trimming up frayed menisci in arthritic knees).
Just imagine what an American reporter would do with a story of a handsome elderly man, wishing to run more marathons, who complains that Medicare denied a knee surgery his orthopedic surgeon recommended. The bottom line that the surgery is actually worthless, according to good clinical trials, would never reach the screen, the reporter instead relying on testimonials from other patients who claim the procedure got them their life back.
Unfortunately, American politics and the media continue to devolve farther and farther away from adult conversations about difficult issues. I commend my British colleagues for showing us that human psychology and public discourse still allow for making difficult decisions at the national level, where public institutions have to live within their means.
Maybe one day, we could get a bunch of British GPs and their patients to perform at Shea Stadium. Maybe that would be the catalyst to awake the Americans to the innovations coming from the other side of the pond. A boy can dream!
Keep calm and ration on.
Yes, if we had more sense, we wouldn’t fall for all these “bad insurer” stories. https://lowninstitute.org/news/blog/the-narrative-of-bad-insurer-hides-bad-evidence/
Occasionally, the “bad insurer” really is; but most times this is just an “insurance should pay any amount of money for anything a doctor endorses regardless of benefit or cost,” and is great propaganda for those who want to make a lot of money selling not-worth-the-cost medical procedures or drugs.
Rationing is not a bad word.
Most of the orthos in my area will do knee and hip replacement on patients with a BMI over 40; really. I had a 90 year old lady have a knee replacement in April; they didn’t even address her other issues like atrial fib.
I am thrilled to find your blog (from Kevin MD). Do you know of any organizations (formal or informal) that are trying to have a public conversation about rationing? Other than individual blogs like yours (which are so important), are there any groups of people (other than Hastings and the occasional journal article) that are trying to formulate a cogent, long term conversation that would respond to the standard scare tactics? Of course the timing may not be right–but when has it ever been right? Thanks so much.
Mr. Chatterjee,
Thank you so much for your encouragement and courage to even talk about the difficult topic of resource allocation in healthcare or rationing. I’m not aware of any single group or place for this kind of conversation. It’s been made even harder in the U.S., because one of the laws enacted before the PPACA included a line that Medicare cannot consider cost-effectiveness in its coverage decisions (incremental cost-effectiveness ratios, QALYs, etc.). Of course, no insurance company will lead this conversation. The closest we come in the U.S. to what you’re talking about, as far as I know, is the Choosing Wisely Campaign and the Lown Institute’s Right Care Alliance (https://rightcarealliance.org/). Both of these groups are at least trying to reduce silly utilization, but nothing in the U.S. comes close to the honest and thorough conversations they have in other developed countries, especially the UK.