Lessons for American radiology from the United Kingdom.

Professors Brindle and Watt of the Royal College of Radiologists report on the changing scene for the practice of radiology in the United Kingdom [1]. The authors have a positive report about radiology “across the pond,” with a growing clinical demand, increased interest in radiology training by medical graduates, and an increase in the number of positions for radiologists supported by the National Health Service (NHS). But the times are changing, even in staid Great Britain. The NHS was organized in 1948, after World Wan II. For nearly 50 years the NHS has changed little and has grown into the langest health service in Europe. Although politically governed, it has undergone minor adjustments with the changes in political control between the Labor Party and the Tories and has always been administered centrally and funded completely by federal taxation. By American standards, it has many attributes of a successful program-its cost is only 5.65% of the gross domestic product, on approximately $1100 pen citizen pen year. It is essentially a free service to all citizens (and most visitors) at the point of cane. This relatively low cost and access to medical care for all are goals that the United States has found impossible to achieve. Much of their success results from a consistent medical cane strategy where as much cane as possible is delivered by a family practitioner who is capitated for each person on his or hen “list” and who controls access to specialty and hospital cane. Essentially all specialty care, including radiology services, is provided by a coordinated network of hospitals. Each locale has a general hospital that provides certain services, including basic radiology. The hospital network also includes a few specifically identified regional hospitals that provide what we would consider tertiary care. The NHS has not allowed mixing of services, and primary, secondary, and tertiary care are provided only in specific locations. This is contrary to medical practice in the United States, where sometimes a 200-bed local hospital provides the gamut of services from a single office visit through solid organ transplants. Brindle and Watt report a radical change in the United Kingdom. The problem is twofold: There are increasingly vocal complaints from British citizens and their politicians about the long waits for specialty care, including radiology services; and medical cane is perceived as costing too much, even though the cost is about half that in the United States. The proposed solution, announced in 1990, is to change the NHS toward a system analogous to health maintenance organizations and managed care in the United States. Although the NHS will continue to fund the local health cornmissioners, the commissioners are encouraged to continue to capitate the family practitioner for primary care but now to promote larger risk taking and to capitate the family pnactitionen to take on the responsibility for total patient care and become a gatekeeper as is the case in many health maintenance organizations in the United States. The number of totally capitated family practitioners in the United Kingdom, who are called fund-holding family practitioners, is growing. With this change, the NHS is distancing itself from medical care providers, and the local health commissioners (who are becoming the purchasers) or capitated fund-holding family practitioners are now requiring the hospitals and medical specialists to compete for contracts to provide specialty care. This new capitalistic and entrepreneurial approach