What Britain’s ‘lousy’ NHS does better than America’s system

Like all modern healthcare systems, the National Health Service -- Britain‘s centralized, universal healthcare system -- has room for improvement. But there’s much more to the story than that presented by Dr. Theodore Dalrymple in his Aug. 8 Op-Ed article, “Britain’s cherished, lousy National Health Service.”

The NHS’ widely known strength is primary care. And time and again it has been shown that a strong primary-care system is at the heart of a healthy population. In part because of Britain’s focus on primary care, the country has lower age-adjusted rates of diabetes (about half our rate), heart disease (about two-thirds our rate) and cancer (about half our rate), as shown in a 2006 study published in the Journal of the American Medical Assn. And in terms of rates, this disparity between the two countries might be understated. Unlike Britain, the United States still has roughly 50 million people who may never have been screened for any of these diseases simply because they are uninsured.

The British certainly do have poorer outcomes for some diseases than we do. The United States is widely respected for its advances in cancer care, but the results are arguably only marginally better.

Consider this: The United States spends at least double per person what most other developed countries (including Britain) spend on healthcare to get these better outcomes. So the 30-day heart attack mortality rate difference reported by Dalrymple (6.3% in Britain versus 5.1% in the United States) seems almost silly once you consider what we spend to get there. And is it really worth spending double to get a boost of 1.2 percentage points in “survival” among those diagnosed rather than reduce the rate of heart disease to levels comparable with Britain in the first place? Is it worth spending double to get a 15-percentage-point increase in five-year “survival” for those diagnosed with colon cancer rather than apply the funds to reduce cancer rates to levels comparable with Britain in the first place?

It’s telling (and certainly predictable) to see that the British do better than anyone else in preventing one of the major sequelae of diabetes (amputation). And it’s interesting to see that this success is mentioned almost dismissively by Dalrymple, considering that if you’re managing diabetes well and preventing amputation, you’re probably also doing much to manage the other major complications of it (retinopathy, stroke, heart attack and so on).

Of course, the reason that the amputation result is predictable is that diabetes can often be well (or arguably better) managed in primary care because it involves not just regular medication management and oversight but ongoing health education and support for major lifestyle changes. And guess which country has a strong primary-care system? Broken record, I know.

It is worth noting that the NHS has made this choice rationally: spend money to prevent rather than money to treat. In an ideal world, we would focus on both. But if we have limited resources, there’s an obvious choice.

And that choice certainly does not make the NHS “lousy.”

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Gregory D. Stevens is an assistant professor of family and preventive medicine at USC’s Keck School of Medicine.

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