What can the UK and US health systems learn from each other?
http://www.100md.com
《英国医生杂志》
1 Ovations, PO Box 1459, Minneapolis MN 55440, USA, 2 UnitedHealth Europe, London SW1P 1SB
Correspondence to: R Smith Richard_S_Smith@uhc.com
The NHS and US insurance based health systems seem worlds apart. Despite the differences, each has much to learn from examples of good practice in the other
We thought it important for this article to have a prelude on learning, but we want now to identify opportunities for transatlantic learning. Although we can outline opportunities, true innovation will come from joint projects. The box lists some of the examples of learning we considered, but we have space here to consider only four—two in each direction. We've deliberately avoided some of the more obvious learning points—like the new general practitioner contract, the National Institute for Clinical Excellence, the care of patients with long term conditions, and the integration of primary and secondary care in a model like that of Kaiser—which have been well covered elsewhere.1 5-8
Opportunities for the United Kingdom
Modernising professional learning
Continuing medical education (CME) in the United States is a multibillion dollar business funded largely by pharmaceutical companies. Much of it comprises traditional forms of education, with "experts" (often funded and even invited by the pharmaceutical companies) giving lectures to non-experts. The result is little learning and no change in practice,11 but physicians need to accumulate "CME points" in order to remain in their specialty practice.
The United Kingdom also has its share of this expensive but largely ineffective enterprise, but it is increasingly recognising that it's possible to do much better. Every doctor in the United Kingdom is now required to have a personal development plan, and this must be built from a "diagnosis" of learning needs. Doctors measure their competencies against those needed for their specialties. The General Medical Council has defined the competencies needed by all doctors,12 and various specialist groups, including for example, the Royal College of General Practitioners, have defined the extra competencies needed for their specialties.13 Professional bodies in the United States have not defined what is a good doctor, but without such a definition it is impossible to know whether professional examinations are measuring what they should be measuring.
Many other tools can be used to identify the learning needs of doctors, including some that are derived from interactions with patients. Once they have identified their needs, doctors in Britain are required to show how they respond to those needs, recognising that there are many different ways to learn and that individual doctors will have different learning styles. A record of their needs and the responses is kept in a personal development plan, which must be presented during the annual appraisal that is now required for all doctors in Britain.
Increasingly, doctors are also encouraged to learn with other professional groups. Multidisciplinary learning has long been praised but hasn't happened much. Now it is beginning to happen. We lack the evidence that this new form of learning will improve patient care, but there are sound educational reasons for thinking that it will be much superior to a diet of lectures from experts.
Using information technology to improve patient care and experience
The Institute of Medicine, which we praised above, advised that moving from a paper to an electronic based system would be the single step that would most improve patient safety.9 At the moment, patient records are often not available when patients are admitted for emergency care and are regularly lost in routine care. Furthermore, they are held in multiple places and are disorganised. For patients with long term or complex conditions, it can be impossible to find essential information in the bulging and often disintegrating files.
In addition, health care has heavily underinvested in information technology compared with other enterprises (fig 3). Those who pay for health care have understandably put investment in staff and treatments before investment in technology, but in the long term this is a mistake. Health is a knowledge based enterprise, and yet the knowledge has been disorganised and often inaccessible.
Fig 3 Annual expenditure per employee on information and communication technology in United Kingdom in different economic sectors, 2000
In 2002, a major report on the needs of the NHS over the next 20 years concluded that "without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient high quality service, which the public will demand."14 A massive programme—the National Programme for Information Technology—is now under way in England.15 It is costing more than ￡6bn ($11.3bn, 8.7bn), will take 10 years, and aims to link all parts of the NHS so that records will be accessible everywhere and to provide a platform for the employment of increasingly sophisticated information tools.
Unsurprisingly, the programme faces major hurdles, but the first stage of procuring and installing the technology is well under way; the government seems to have used its buying power effectively. The next stage of encouraging people to change the way they work will be both more difficult and more important in terms of delivering value from the investment.
Some parts of the US health system use information technology very effectively, particularly the Veterans Health Administration, but the biggest benefits depend on having information systems that work right across a health system, providing information on patients no matter where they may travel or which doctors or institutions they might use. Groups in the United States have recognised that an improved information technology system may be the "big hope" for improving the quality of health care and slowing the relentless rise in costs. But within the fractured US health system it's hard, perhaps impossible, to find organisations willing to make the huge investment that is needed to "wire the whole system." If the UK programme can show that substantial improvements can flow from such a major investment, pressure to find a way to do something similar in the United States will grow.
Summary box
Learning across health systems comes mostly from joint projects
The United Kingdom would benefit from having an organisation like the US Institute of Medicine
Europe should consider building a network of high performance, low cost centres to do complex procedures
The United States is wasting large sums on old fashioned continuing medical education, whereas Britain is modernising professional learning
The US would benefit from system-wide information technology such as that being introduced in England
Conclusions
Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente . BMJ 2002;324: 135-43.
Correspondence. Getting more for their dollar: Kaiser v the NHS. BMJ 2002;324: 1332-5.
Talbot-Smith A, Gnani S, Pollock AM, Gray DP. Questioning the claims from Kaiser. Br J Gen Pract 2004;54: 415-21.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327:1257-60 (full version on bmj.com).
Senge P. The fifth discipline: art and practice of the learning organisation. New York: Random House, 1993.
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rawlins MD. NICE work—providing guidance to the British National Health Service. N Engl J Med 2004;351: 1383-5.
Murphy E. Case management and community matrons for long term conditions. BMJ 2004;329: 1251-2.
Committee on the Quality of Healthcare in America. To err is human: building a safer health system. Washington, DC: Institute of Medicine, 1999.
Committee on Quality of Healthcare in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine, 2001.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268: 1111-7.
General Medical Council. Good medical practice. London: GMC, 1998.
Royal College of General Practitioners. Good medical practice for general practitioners. London: RCGP, 2002.
Wanless D. Securing our future health: taking a long term view. London: HM Treasury, 2002. www.hm-treasury.gov.uk/Consultations_and_Legislation/wanless/consult_wanless_final.cfm (accessed 14 Feb 2005).
Humber M. National programme for information technology. BMJ 2004;328: 1145-6.(Lois Quam, chief executive officer1, Ric)
Correspondence to: R Smith Richard_S_Smith@uhc.com
The NHS and US insurance based health systems seem worlds apart. Despite the differences, each has much to learn from examples of good practice in the other
We thought it important for this article to have a prelude on learning, but we want now to identify opportunities for transatlantic learning. Although we can outline opportunities, true innovation will come from joint projects. The box lists some of the examples of learning we considered, but we have space here to consider only four—two in each direction. We've deliberately avoided some of the more obvious learning points—like the new general practitioner contract, the National Institute for Clinical Excellence, the care of patients with long term conditions, and the integration of primary and secondary care in a model like that of Kaiser—which have been well covered elsewhere.1 5-8
Opportunities for the United Kingdom
Modernising professional learning
Continuing medical education (CME) in the United States is a multibillion dollar business funded largely by pharmaceutical companies. Much of it comprises traditional forms of education, with "experts" (often funded and even invited by the pharmaceutical companies) giving lectures to non-experts. The result is little learning and no change in practice,11 but physicians need to accumulate "CME points" in order to remain in their specialty practice.
The United Kingdom also has its share of this expensive but largely ineffective enterprise, but it is increasingly recognising that it's possible to do much better. Every doctor in the United Kingdom is now required to have a personal development plan, and this must be built from a "diagnosis" of learning needs. Doctors measure their competencies against those needed for their specialties. The General Medical Council has defined the competencies needed by all doctors,12 and various specialist groups, including for example, the Royal College of General Practitioners, have defined the extra competencies needed for their specialties.13 Professional bodies in the United States have not defined what is a good doctor, but without such a definition it is impossible to know whether professional examinations are measuring what they should be measuring.
Many other tools can be used to identify the learning needs of doctors, including some that are derived from interactions with patients. Once they have identified their needs, doctors in Britain are required to show how they respond to those needs, recognising that there are many different ways to learn and that individual doctors will have different learning styles. A record of their needs and the responses is kept in a personal development plan, which must be presented during the annual appraisal that is now required for all doctors in Britain.
Increasingly, doctors are also encouraged to learn with other professional groups. Multidisciplinary learning has long been praised but hasn't happened much. Now it is beginning to happen. We lack the evidence that this new form of learning will improve patient care, but there are sound educational reasons for thinking that it will be much superior to a diet of lectures from experts.
Using information technology to improve patient care and experience
The Institute of Medicine, which we praised above, advised that moving from a paper to an electronic based system would be the single step that would most improve patient safety.9 At the moment, patient records are often not available when patients are admitted for emergency care and are regularly lost in routine care. Furthermore, they are held in multiple places and are disorganised. For patients with long term or complex conditions, it can be impossible to find essential information in the bulging and often disintegrating files.
In addition, health care has heavily underinvested in information technology compared with other enterprises (fig 3). Those who pay for health care have understandably put investment in staff and treatments before investment in technology, but in the long term this is a mistake. Health is a knowledge based enterprise, and yet the knowledge has been disorganised and often inaccessible.
Fig 3 Annual expenditure per employee on information and communication technology in United Kingdom in different economic sectors, 2000
In 2002, a major report on the needs of the NHS over the next 20 years concluded that "without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient high quality service, which the public will demand."14 A massive programme—the National Programme for Information Technology—is now under way in England.15 It is costing more than ￡6bn ($11.3bn, 8.7bn), will take 10 years, and aims to link all parts of the NHS so that records will be accessible everywhere and to provide a platform for the employment of increasingly sophisticated information tools.
Unsurprisingly, the programme faces major hurdles, but the first stage of procuring and installing the technology is well under way; the government seems to have used its buying power effectively. The next stage of encouraging people to change the way they work will be both more difficult and more important in terms of delivering value from the investment.
Some parts of the US health system use information technology very effectively, particularly the Veterans Health Administration, but the biggest benefits depend on having information systems that work right across a health system, providing information on patients no matter where they may travel or which doctors or institutions they might use. Groups in the United States have recognised that an improved information technology system may be the "big hope" for improving the quality of health care and slowing the relentless rise in costs. But within the fractured US health system it's hard, perhaps impossible, to find organisations willing to make the huge investment that is needed to "wire the whole system." If the UK programme can show that substantial improvements can flow from such a major investment, pressure to find a way to do something similar in the United States will grow.
Summary box
Learning across health systems comes mostly from joint projects
The United Kingdom would benefit from having an organisation like the US Institute of Medicine
Europe should consider building a network of high performance, low cost centres to do complex procedures
The United States is wasting large sums on old fashioned continuing medical education, whereas Britain is modernising professional learning
The US would benefit from system-wide information technology such as that being introduced in England
Conclusions
Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente . BMJ 2002;324: 135-43.
Correspondence. Getting more for their dollar: Kaiser v the NHS. BMJ 2002;324: 1332-5.
Talbot-Smith A, Gnani S, Pollock AM, Gray DP. Questioning the claims from Kaiser. Br J Gen Pract 2004;54: 415-21.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327:1257-60 (full version on bmj.com).
Senge P. The fifth discipline: art and practice of the learning organisation. New York: Random House, 1993.
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rawlins MD. NICE work—providing guidance to the British National Health Service. N Engl J Med 2004;351: 1383-5.
Murphy E. Case management and community matrons for long term conditions. BMJ 2004;329: 1251-2.
Committee on the Quality of Healthcare in America. To err is human: building a safer health system. Washington, DC: Institute of Medicine, 1999.
Committee on Quality of Healthcare in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine, 2001.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268: 1111-7.
General Medical Council. Good medical practice. London: GMC, 1998.
Royal College of General Practitioners. Good medical practice for general practitioners. London: RCGP, 2002.
Wanless D. Securing our future health: taking a long term view. London: HM Treasury, 2002. www.hm-treasury.gov.uk/Consultations_and_Legislation/wanless/consult_wanless_final.cfm (accessed 14 Feb 2005).
Humber M. National programme for information technology. BMJ 2004;328: 1145-6.(Lois Quam, chief executive officer1, Ric)