The United Kingdom's National Health Service (NHS) is celebrating its 75th anniversary this month. Long hailed as a model health system that provided universal coverage and high-quality care without overly taxing the national budget, the NHS has fallen on hard times. It faces challenges of underfunding, an aging and unhealthy population, an inadequate and increasingly exhausted workforce, and a projected shortage of hospital beds. The headline of a New England Journal of Medicine article asked if the NHS was "at breaking point or already broken?" The widely reported failures of the system to meet patients' basic needs since December 2022 - a time when it should have been recovering from the stresses of the pandemic - has caused public confidence to plummet:
The unspoken agreement between the NHS and U.K. residents was that despite some rationing of care, regional differences in service availability, and the often aging and less-than-sparkling premises, in the event of a medical emergency, an ambulance would arrive promptly and high-quality care would be available at a hospital without anyone requiring an insurance card. That agreement has been broken, and satisfaction with the service is at record lows.
It likely provides little consolation to our neighbors across the pond that the U.S. is in an even sorrier state despite spending twice as much of our gross domestic product per capita on health care services. But the U.K. seems determined to add insult to injury. Despite the resoundingly negative result of the country's only major randomized trial of PSA-based screening, the NHS seems poised to roll out a population-based prostate cancer screening program. (Currently, U.K. men over age 50 can request to have PSA testing, but doctors are not encouraged or incentivized to provide the test routinely to their eligible patients.) They need only look to the U.S. to see that this decision would be a public health disaster that would produce millions of new (mostly overdiagnosed) cancer patients and divert resources away from other primary care preventive care services with a much better likelihood of improving health.
As Dr. Andrew Vickers and colleagues wrote in a recent BMJ article, the prevailing approach to PSA screening in the U.S. and other high-income countries of "informed choice" or "individual shared decision making" drives high rates of testing in older patients who are least likely to benefit and most likely to be harmed, leading to overdiagnosis and inequities:
Approaches to PSA testing that rely on people making an informed choice are likely to reflect and reproduce health inequities in preventive healthcare. Data from Canada, the US, and Switzerland suggest PSA testing is inversely associated with income and education; in Canada and the US, PSA testing is less common in people from ethnic minorities. In the UK and Switzerland, rates of PSA testing are lower in economically deprived areas. Although the effects of disparate rates of PSA testing on health outcomes are still unclear, countries should decide who gets offered screening based on a risk assessment rather than leaving it to individuals.
