Much maligned in the news in the month of August was the UK's National Health Service. Eric's mom-- who also sent me
-- was out here for a visit last week and happened to be staying in a B&B with a physician from the UK's National Health Service. I'm grateful to her and to Dr. Stephen Shepherd for letting me reprint some of his thoughts on this health care debate.
SOME THOUGHTS OF A VISITING GP Whilst visiting San Francisco in August 2009 a few thoughts occurred to me concerning the current debate in the US about the proposed changes to the US Health care system and comparisons with the UK's NHS.
In every country in the world there are basically only 3 ways of accessing health care.
The rich simply pay cash for whatever they want.
Those with health insurance received 'managed care'
The poor are thrown on the basic healthcare provided by the State
In the UK the NHS covers both the last two catagorys. The standard of care for ALL is equivalent to the managed care received by US citizens with insurance. A few people in the UK have private health insurance, usually as a perk of their job. In the past this allowed you to bypass some of the NHS queues. Nowadays, with the better financed NHS, private health insurance tends just to allow you to have private room, rather than share a 4-bedded bay, which is the norm in NHS hospitals.
The vast majority of hospital specialists or Consultants do most of their work in the NHS and do private work to supplement their NHS income. Private hospitals are not really set up for complex procedures and if you are seriously ill you are best off with the NHS.
The key to the NHS is the General Practitioner or GP (Primary Care Physician). Your GP will refer you for both NHS and Insurance referrals, but will provide the bulk of your care. Most chronic diseases in the UK are dealt with by the GP, who will know you and your past history and will tailor your healthcare for you personally. Primary Care is very strong in the UK.
Now to deal with a few points:
Rationing: all healthcare is rationed, except for the rich. In the UK most treatments are covered by the NHS and your doctor is free to prescribe any drug or treatment that is marketed in the UK. The exceptions are new expensive treatments whose clinical effectiveness are assessed by an independent body called the National Institute for Clinical Excellence (NICE), before they become widely available on the NHS. In the US health care is rationed by the Insurance companies managed care system, or by your ability to pay. I understand it is not unknown for people to die in the US as they lack the money to fund their treatment. I leave the reader to decide which is the better system.
Waiting Times and Choice: in the past the wait for routine procedures could be measured in years, but since the advent of Tony Blair's Labour Government a lot of money has gone to improve matters. As a GP I can use the new Choose and Book computer system to book appointments during a patient's consultation, at a time and date of their choosing. Most routine appointments will be within a month. It is unusual for the wait for surgery to be more than 3 months. If your GP thinks you may have cancer, there is a rapid access system which gets you to see a Specialist within 2 weeks and any definitive treatment started within a month.
Quality: British doctors are trained to the same standard as those in the US and foreign graduates wanting to work in the UK must have a good standard of English and meet the clinical standards set by the various Royal colleges that supervise training in the UK.
Income: when the NHS was set up in 1945 many doctors feared that they would be out of pocket. This has proved to be far from the case. Most GPs earn £120000 from the NHS with very little from private work. Experienced nurses earn from £20-30000. Hospital Consultants earn around £100000 from the NHS, but their additional private income can vary from zero to £100000+ according to their speciality and/or personal choice.
Innovation: the charge that the NHS discourages innovation and invention just makes me laugh. The route to being a hospital consultant is through research. All hospital consultants only get their position once they have done some research and continue to do so once in post. British drug companies are amongst the best in the world and around 40% of current treatments had their origins in the UK.
I admit to wondering what lies behind the opposition to President Obama's health care reforms. I suspect that many Americans realise that sorting out your healthcare system will inevitably lead to other social reforms.
The NHS is a small part of a whole raft of social benefits that make up the British Welfare State.
Benefits are provided if you are unemployed, sick, disabled or caring for someone who cannot care for themselves. Everyone gets an old age state pension from 65. The elderly are one of the main beneficiaries of the NHS. Should you need residential or nursing home care as you get older then the state pays for that and allows you to keep significant personal assets.
The poor and other disadvantaged groups are not left to fend for themselves on the streets. Local government in the UK has a statutory duty to provide social housing for all who need it, together with social services care. The homeless are not left to roam the streets, but are housed in hostels, where they have their own lockable room. These hostels provide temporary accommodation until the local authorities can find somewhere permanent, usually in the form of a one or two bed apartment.
This extensive welfare system is the result of the Socialist Government of 1945 and is the result of the report carried out by Beveridge in the later years of WW2. It is important for Americans to remember that the UK, and Europe in general, is far more left wing than the US. The main British right wing party, the Conservatives, are much more akin to left leaning Democrats. The Labour Party is a left wing party that has moved a little more to the right under Tony Blair. Some of the views I have read from Republicans would have no place in British politics, except in our extreme right wing parties like the British National Party (BNP), who are viewed with contempt by the majority in the UK.
The downside of course to the Welfare state is the cost. Income tax in the UK starts at 20% and rises to 40% on any income in excess of £38000.
On mainland Europe the Social care systems are more generous than the UK, but their income tax rates are higher. In the US it seems you provide very minimal benefits, but have low income tax.
In the UK we have gone for the middle ground between the two.
A UK style system would almost certainly lead to the US middle class losing their mortgage tax relief, as happened in the UK. Perhaps this is the main reason for the opposition?
Benefits in the UK are aimed at providing a comprehensive safety net with benefit levels set to allow you to survive and stay in your own home. No one would choose to stay on benefit as even a modest income will give a better quality of life. For instance, except in times of recession, most people made unemployed would have found a new job within a month. The UK is still a net importer of employees.
A few people do slip through the net, especially in London, but people begging on the street is unusual in the UK and often they are people who have great difficulty engaging with any form of authority. Strenuous efforts are made by many state and charity groups to engage with these individuals.
Remember even these people have the right to see a GP and access all parts of the NHS. I have worked for a practice that provided services targeted at the homeless.
I am shocked whilst in the US, the richest country in the world, to see such affluence along side such abject poverty.
I would like to remind the US: 'No man is an island.'
Dr Stephen Shepherd, GP