Dr. Berwick, now appointed to a US panel to shape US heath care, is an admirer of the UK system of health care, which includes limiting or rationing of it’s care.

So this week, two stories are coming out of the UK on health care.

One is a report that more autonomy will be given to GP’s in deciding their patient’s care.

But the second, if true, is ominous.  The UK Telegraph reports:

An investigation by The Sunday Telegraph has uncovered widespread cuts planned across the NHS, many of which have already been agreed by senior health service officials. They include:

* Restrictions on some of the most basic and common operations, including hip and knee replacements, cataract surgery and orthodontic procedures.

Lots more information at the link. They also plan to restrict IVF (AKA “testtube fertilization”) and surgery for obesity.

Local docs will be encouraged to care for more patients without hospitalizing them or doing tests, while, more ominously, there will be a big cut in “end of life” care.

Well, waiting lists are already part and parcel of the NHS, as this government survey shows.

This will undoubtably be publicized by the right to criticize the Obama Health Care plan, which no one really knows anything about, but which is supposed to include a lot of regulations telling docs who to treat and how to treat them, or else.

Yet for those of us who worked for the US Federal government, none of this is new.

If you are Native American, and rely on your medical care at an IHS clinic, you may only be able to get one or two drugs per category. Emergencies and life or limb threatening surgery will be paid for, but if you want a knee replacement, even seeing an orthopedist might take time. If you have a local IHS hospital with the needed specialist, you might wait for an appointment. If that takes too long, or if your area doesn’t have a specialist there or an outside specialist holding regular clinics there, it means 1) finding a specialist who will take you (the payment tends to be low, so many will only see emergency cases). 2) getting the funding committee to okay your visit. This can take weeks for non emergency care. and then 3) waiting for a specialist appointment. In rural America, specialists are busy, so if it’s not an emergency, you might have to wait a month or two for an appointment.

So essentially, if you could use a knee or hip replacement, the wait will be long.

Obesity surgery? We rarely referred, even though our obesity rate was high and Diabetes was epidemic.

The good news is that we prioritized funding to get nutrition education, podiatry care (to prevent amputations) and often the tribe built exercize facilities for patients to use.

Yet other items in the NHS list like IVF or other fertility surgery (including all non medically indicated abortions) aren’t paid for at all.

Ironically, all the time when  the Obama health care bill and it’s “rationing” aspects were discussed, I rarely saw anything written about the IHS and how “guidelines” to limit spending was already being done by the Federal government.

Indeed,makes me wonder since Dr. Berwick likes the NHS system in England, if he ever bothered to look at the IHS system in the US.

Of course, there is one big difference between the NHS and the IHS: End of life care.

From the UKTelegraph:

On Thursday, the board of Sutton and Merton primary care trust (PCT) in London agreed more than £50 million of savings in two years. The plan included more than £400,000 to be saved by “reducing length of stay” in hospital for the terminally ill.

As well as sending more patients home to die, the paper said the savings would be made by admitting fewer terminally ill cancer patients to hospital because they were struggling to cope with symptoms such as pain. Instead, more patients would be given advice on “self management” of their condition.

So if you are miserable and dying, no money will be spent helping you to be comfortable in the hospital? Ah yes, but only if you agree to it.

Bill Gillespie, the trust’s chief executive, said patients would stay at home, or be discharged from hospital only if that was their choice, and would be given support in their homes.

I agree hospice care is the way to go, but only if the family can do it. But cutting funds will mean pressuring people to die at home, even when their extended families may not be able to cope with it.

At least, in the IHS, we could arrange hospice comfort care for our patients, who often came home from the city to die with the extended family there.  Because of the distances, despite our many visiting nurses, hospice type care was difficult, so often “end of life” care meant a quiet room in the hospital where your extended family could visit and stay with you.

The danger is that limiting care in any way (even by “scientific” methods) will result in the idea that the elderly, the dying, and the handicapped won’t get better, so why “waste money” on them?

It is this insidious mindset  that worries me.

Rationing of “elective” treatments, I can live with, but not callousness to the most vulnerable.

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Nancy Reyes is a retired physician living in the rural Philippines.

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