Letter From London

I’ve just returned from a few days in London, scoping things out for a planned sabbatical next fall. In what may be a pale echo of the late Alistair Cooke’s always fascinating “Letters From America,” here are a few of my initial observations:

The dominant issue, of course, is the Cameron government’s new austerity program, with its planned deep cuts to government services and benefits. While the program (or programme, I guess I should say) has created some upheaval – witness the recent semi-violent demonstrations by university students, whose tuitions may treble – it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America. My sense is that the relative acceptance (yes, I know Charles and Camilla had a frightfully awful limo ride to the West End the other night, but this was, er, theater rather than a defining moment) can be explained the Brits’ stronger trust in their government. It is this same trust that leads to near-universal support for the National Health Service, the UK’s tax-funded healthcare system. This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”

In the US, there is no such trust today, nor harbingers of its return any time soon. In a recent issue of Time that outlined this past decade’s mega-trends, Nancy Gibbs observed that the cumulative effect of 9/11, Katrina, BP and the subprime crisis was to markedly shrink Americans’ already scanty faith that their government can do anything competently. So our response to the recent announcement that Chinese kids are shellacking us in educational achievement is hand wringing and statistical nitpicking, not the call for vigorous government action that characterized our nation in the Sputnik era.

Moreover, in the US, our skepticism about government has been amplified by something even stranger: a profound and growing mistrust of elites. By elites, I’m not referring to the “moronic wealthy,” as one of my new English friends described the archetype personified by Dudley Moore’s character in “Arthur.” No, in the UK, I’m referring to the Cambridge/Oxford intelligentsia, who wield disproportionate power in the halls of Parliament. There is little sense in England that the government would be well served by replacing these elites with “real people.” On the other hand, in today’s America, being an educated Ivy League grad is seen as a liability (healthcare’s Exhibits A and B are those brilliant Harvard professors, Drs. Berwick and Blumenthal). The counterpoint, of course, is Sarah Palin (whom the British were endlessly curious about). As Frank Rich recently observed when discussing Palin’s seemingly unstoppable circus act,

What might bring down other politicians only seems to make her stronger: the malapropisms and gaffes, the cut-and-run half-term governorship, family scandals, shameless lying and rapacious self-merchandising. In an angry time when America’s experts and elites all seem to have failed, her amateurism and liabilities are badges of honor. She has turned fallibility into a formula for success.

The UK’s healthcare issue of the moment is the decision by the government to completely upend its system of Primary Care Trusts: an 8-year old program that created regional, professionally-managed entities to receive and then dole out fixed budgets to purchase healthcare for large populations of patients – sort of like our HMOs, but funded with tax dollars. The decision to pull the plug on the PCTs is a very big deal: today, they manage 80 percent of all NHS funds. Faced with rapidly rising costs and some scandalous instances of service and safety lapses, the coalition government decided not to tweak the Trusts but to scrap them entirely. The solution, to be implemented over the next 2-3 years: replace the Trusts with consortia run by General Practitioners, England’s version of our primary care physicians.

This is interesting, since, as my businessman father always drummed into me, God has not invented a class of people worse at running businesses or investing money than doctors. But, as one British physician-leader told me over a delightful pub dinner, the Cameron government came to believe that the only way to get a subspecialist to think about adopting a less expensive practice style – for example, pushing expensive chemo on a patient with little time left – was to create an environment in which another physician, not a manager, was the one to tap the oncologist on the shoulder and ask him about the appropriateness of the full court press. “To catch a thief, know a thief,” quipped my colleague. GPs are said to be ambivalent about the new responsibility they’ll soon be assuming. Some seem pleased about the infusion of power and money; others prefer to stick to their knitting.

In Great Britain, it’s the knitting that pays for GPs. These physicians are not the same downtrodden and status-challenged group as PCPs are in the US: a senior GP can make $300K/year, substantially more than the average specialist! It’s hard to imagine, but many medical students in Britain choose primary care careers for the money.

I don’t know enough about Britain’s new GP commissioning plan or the overall deficit reduction scheme (which the government has euphemistically labeled the “Big Society“) to decide whether they are good ideas. But what strikes me most about both initiatives is the public’s acceptance, seemingly, of rather staggering degrees of transformation. In the US, this would be the equivalent of our Congress signing onto the Simpson/Bowles deficit reduction plan, or a similarly ambitious plan to combat global warming – inconceivable, as our fractured political system would not allow change that ambitious. Creeping incrementalism R Us, for better or worse.

Mostly worse, I think.


I’ll be in England, studying patient safety with Prof. Charles Vincent and colleagues at London’s Imperial College, from next June to December. I’ll share additional thoughts with you as I learn more about their system – and, with the perspective on one’s own world that only distance can afford, about ours.


  1. Alice Hadley on December 13, 2010 at 6:06 am

    I look forward to hearing about your experience in Gt. Britain.

  2. Richard Smith on December 13, 2010 at 8:40 am

    It’s always interesting to see how you are regarded by others, and your observations on us British are acute.

    As somebody who scuttles backwards and forwards across the Atlantic, I feel that there are two major differences between the British and Americans, one of which you observe.

    1. In Britain if we have a big problem we expect the government to fix it. In the US people tend to think that government will make the problem worse. Having said that, I’m interested that there is much more agreement in Britain with the idea of shrinking the size of government (20% cuts in many departments) than there seems to be in the US.

    2. Britain is essentially a post-religious society, whereas religion is clearly very important in the US. If you want to be president you have to believe, whereas British prime ministers hide their beliefs.

    Something I hadn’t grasped but which you explain is how it’s positively a bad thing for a politician to have been educated at Harvard or another major university. Academics are to be tolerated not encouraged, and you are right that we British are fascinated by Sarah Palin and can’t begin to understand her appeal.

    We are very different countries.

  3. Liam Farrell on December 13, 2010 at 4:42 pm

    Good to see ourselves as others see us, Bob. A small point is that no GP makes £300K per year, but it hides a deeper truth. As GPs and hospital doctors, we have no financial incentive to treat or not to treat patients; they are not clients nor financial units. I essentially get paid the same for a patient who never attends the surgery as for someone who beats the door down every day (not infrequent).
    I think because of this there is a deep trust in the NHS, that though it may be sometimes clumsy and bureacratic, that the waiting lists may be too long, it actually cares and is full of people doing the best they can for you

  4. Bob Wachter on December 13, 2010 at 5:05 pm

    Thanks for these comments. Richard Smith, of course, is the former editor of the BMJ and as astute an observer of medicine (and life) everywhere as I’ve met. I completely agree with Richard about the role of religion in our two societies: only after stepping down from his government role did Tony Blair make clear the degree to which religion informs his world view and drives his passion. Had he been US president, he would have been Tweeting about this every few days to keep his poll numbers up.

    And thanks too to Liam. In the US, there are many primary care physicians who are paid like you are: on a fixed salary or through a capitated (per patient, often framed as “per member per month,” PMPM) payment. Others are paid on a pure productivity model. The challenge lies in crafting a payment system that creates the right balance – a Goldilocks set of incentives that promote neither too much nor too little care… but just right.

    A clarification: I didn’t say that GPs make £300K per year; I said 300K dollars. According to my iPhone currency conversion app, that’s 189,270 pounds per year. One can see how easy it is for international misunderstandings to arise – if it really was £300K ($475,511), the airlines would have to add extra flights for all the American PCPs who wanted to emigrate to the UK!

  5. cory on December 14, 2010 at 4:13 pm

    Things that would bring politicians down:

    Gee you think plagiarizing in law school, barely managing not to fail, and then going back and plagiarizing a speech during a presidential campaign might derail a candidate but it seems to have been no bar to becoming vice-president.

    You would think driving a car off a bridge, killing a girl, leaving the scene of an accident, and then concocting two or three unbelievable stories might derail a candidate and it did render him incapable of being president but not the Lion of the Senate.

    You’d think getting caught on camera using cocaine with a woman not your wife might derail a politician but you can still be Mayor of the Nation’s capital.

    You’d think not paying taxes would derail people in charge of the economy but doesn’t seem to have hurt measurably.

    You would think three or four Harvard Law professors who plagiarized might have their careers derailed when an undergraduate who did the same would be expelled or at least suspended for a year but doesn’t seem to be the case.

    You’d think a man who had sexual relations with a subordinate while on the job might have some big trouble, if he worked in a private company he’s probably have to resign but it doesn’t seem to have hurt a certain Arkansas politician.

    Let’s not use a double standard here. Let’s not condemn in the political opposition what is just as common in your own house.    

  6. Fritzel Shuck on December 15, 2010 at 7:59 am

    Nice Post!

  7. Liam Farrell on December 16, 2010 at 5:51 pm

    Bit churlish, Cory, lighten up.

  8. Brad on December 19, 2010 at 7:36 pm

    Great post Bob.

    I stumbled across this recently re: NHS Atlas.

    Incredibly interesting that the UK would experience variation comparable to a FFS, volume driven system like the US, yet the UK docs have incentives to respond to a very different set of signals.  Something to explore, and would really appreciate any readers across the pond taking a stab at elaborating further.

    The more you scratch below the surface of the Dartmouth data, including looking outward (who knew), the more you learn…and the more you ponder.

    Health care, the system that just keeps on giving.

    Brad F

  9. ephraim m on January 16, 2011 at 10:35 pm

    I would like to commend Cory and sound a note of caution to a man who in the realm of medical policy and clinical judgment, Bob Wachter, I strongly respect. I trained in the hospitals of London and surrounding counties (Kent and Canterbury, Swindon) and always there Accompanying the local NHS hospital would be a private hospital staffed by all the NHS physicians as quickly as they could meet their minimal NHS scheduled patients. In Surgery, for example the NHS patient was placed on a “list” to be operated upon, with a wait of 3-6 months (this is in 1998-99); privatelt insured patients register at the private hospital (The Chaucer in Kent) and of course, receive immediate care, as they’ve paid for. This is never discussed in the health care debate when comparatively assessing medical systems.
    Richard Smith, is no paragon of political neutrality and virtue, by American standards. Several months ago on his BMJ blog he lauded the moral integrity of a Russian spy-physician who had, after a lengthy jail term for passing state secrets to the Russians, been released and expelled from Israel. Dr. Smith found nothing reprehensible or morally questionable in spying for Russia. In the USA he would have suffered quite a bit of sustained scrutiny; it slips by in the UK.

    And as for quoting Frank Rich, Rich had been the “theater critic” for the New York Times for year upon year. As NYT”s circulation and quality has perilously plummetted in recent times, he’s been thrust into the role of political commentator, as the once pre-eminent paper spirals downward. What would Rich say about (former President) Harry Truman, another decidedly non-elitist” salt of earth” type politician/statesman. My father has told me Truman was roundly ridiculed for his (like Sarah Palin) unfinished edges as well.

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  11. Sue on February 12, 2011 at 10:18 am

    “it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America.”

    Speaking as a Londoner, I fear this is just the beginning, I think that the effects of the Government’s cuts will have deep repercussions that have only just begun… people are being made redundant and that will cause great problems in the future and there may be trouble ahead….

    I alway remember a quote I read, “Those who matter don’t care, and those who care don’t matter”

  12. Optometry Murrieta on December 3, 2012 at 1:26 pm

    This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”

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