An American Cohort in London: Part I

The recent Supreme Court ruling in King v. Burwell, a landmark decision ensuring the protection of subsidies mandated by the Affordable Care Act, reaffirmed that health care is one of the most complex and contentious issues here in the U.S. Just days after the ruling came down, a group of MHA@GW students traveled to London, England, with Program Director Dr. Leonard Friedman and Dr. Usman Khan, External Advisor on the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care in Northwest London (CLAHRC) program, to learn about a completely different — albeit equally intricate — health care system. The spirit of the trip was quid pro quo: In addition to hearing from regulatory, legislative and clinical experts throughout the city, students were also tasked with presenting to those groups on different facets of the U.S. health care system, from the Affordable Care Act to insurance policy to emergency room flow.

The immersion experience in Health Systems Analysis is one of four required of students enrolled in MHA@GW, the online Executive Master of Health Administration degree offered through the Milken Institute School of Public Health at the George Washington University. It is intended to provide students with a firsthand, contextual understanding of the global health care landscape as they emerge as leaders in the health administration field.

Kickoff Dinner: Reuniting Abroad

In addition to being a unique educational experience, the trip represented a reunion for many students who had become close at previous immersions held on the GW campus in Washington, D.C.; several had even taken a vacation together in Europe in the week leading up to the immersion. Before digging into an intense week of curriculum, the faculty, staff and students had an informal chance to catch up during a welcome dinner at Pescatori in the West End.

The UK Health Care System in Perspective

To help prepare students for a busy week of on-site visits with clinical, regulatory and political organizations throughout London, Dr. Khan, Professor David Taylor of the University College of London (UCL) School of Pharmacy, and Professor John Wyn Owen CB led students through the first official day of the immersion with classroom sessions on the history, legislation, structures and policies that define the British health care system and differentiate it from the U.S. model.

The most significant and oft-cited difference is that the U.K.'s National Health System (NHS) embraces a centralized, state-managed, single-payer system, whereas the U.S. relies on private insurers. However, the week of intensive conversations and presentations revealed plenty of overlap in terms of the challenges health care professionals face regardless of which nation they call home. Establishing and maintaining a high standard when it comes to quality of care is just one example.

"You're only as good as your last interaction, and being able to achieve the quality not just once with patients but on an ongoing basis," Dr. Khan said.

Also like the U.S., the U.K. has seen chronic diseases supersede infectious ones as leading causes of death and primary inhibitors of health. Additionally, the NHS has strived to facilitate and support health care systems that account for the way socioeconomic factors affect individual and community health.

"No health system has it right. Every system does things much different. Do we know the right way to do it all?" — Professor David Taylor, UCL School of Pharmacy

Dr. Friedman acknowledged the intensive nature of the programming as the day’s agenda came to a close — and assured students that the pace would continue throughout the week.

"I realize that this has been an extraordinarily long day, and that many of you are running on fumes right now,” he said. "We don’t call this an immersion for nothing.”

Commissioning Care in the NHS

Day two centered on commissioning care in the NHS, and included visits to the NHS Camden Clinical Commissioning Group and the Caversham Group Practice. Clinical commissioning groups — known colloquially as CCGs — were established by the U.K.’s Health and Social Care Act 2012. CCGs negotiate agreements with service providers in the NHS and in private and voluntary sectors to meet the health needs of particular populations. They’re charged with identifying the most pressing health concerns for specific areas of the city, and determining which services should be in place to help address those concerns. CCG Director of Commissioning Mary Clegg and colleagues presented to students before taking part in an informal lunch and networking session.

Next, the Caversham Group Practice presented on its work providing services to those in need of health care. Practice partners and general practitioners Stephen Amiel and Alex Warners discussed Caversham Group’s role as an established teaching and training practice whose clinics provide rapid access to specialist NHS services — without warranting a trip to the hospital.

MHA@GW Program Director Leonard Friedman presents a GW hippo to Stephen Amiel and Alex Warners

“Continuity of care that adheres in the relationship between a registered patient and their GP,” Amiel said, is at the core of why the U.K. health care system is regarded as one of the most effective in the world at managing the well-being of its populations. As the system continues to undergo transitions, he noted, “continuity of care but also continuity of carer” will be key to maintaining a high quality of service.

Quality, Improvement and Patient Involvement

To better understand the mechanisms that improve health outcomes and patient experience in the NHS, students had the opportunity to sit down with experts in the field of quality, improvement and patient involvement. They spent the morning in one of London’s most iconic and historic legislative centers: the Palace of Westminster. Sir Roger Gale, the Member of Parliament for North Thanet, hosted the group, and he led a session on the legislative side of health care in the U.K.

To learn more about the way research informs quality of care, students engaged with staff at the Collaboration for Leadership in Applied Health Research and Care in Northwest London  (CLACHRC — pronounced “Clark” for short). The organization, part of the National Institute for Health Research, conducts applied health research and helps translate its findings into practices that benefit patients. Ganesh Sathyamoorthy, CLACHRC NWL assistant director for partnerships and business development, reminded students that even a centralized entity like the NHS is composed of many moving parts, and quality improvement can’t happen via a one-size-fits-all approach.

“The NHS is like an ecosystem. There’s no one lever to pull to improve efficiency across all channels and subsystems,” he said. “Rather, let’s think about this from a more systems-oriented perspective. I think we have to embrace this notion of complexity.”

“The NHS is like an ecosystem. There’s no one lever to pull to improve efficiency across all channels and subsystems.” — Ganesh Sathyamoorthy, CLACHRC NWL Assistant Director for Partnerships and Business Development

Meerat Kaur, CLACHRC associate lead for patient and public engagement, presented findings from her research on patient and public involvement within a quality improvement program. Kaur said that responding to system failures throughout British health care is a matter of changing the work culture instead of blaming individuals for things that go wrong. “You can’t take that individual out of the system and expect it to be fixed,” he said.

The trip didn’t end there. Read more about the second half of our students’ immersion across the pond — including a visit to London’s first free hospital and a sunset cruise down the River Thames — in our next roundup post.