For a while I have missed opportunities to write on health care. I try to blog about a topic when it is in the news and fresh in the public mind. For healthcare, however, I kept avoiding posting on it. This avoidance comes partially from the highly contentious nature of the topic. People on both sides of the Pond have strong and often emotional views on the subject. Furthermore, intellectually is a very involved and difficult topic. If I wrote everything that I wanted to write about healthcare, I could spend weeks, months even, doing the relevant research only to write an essay on the topic.
I still want to write about though. People who have lived under both types of medical systems, have a unique, a perspective not tied only to theory.
Given the scope of the topic, I have broken it down into multiple posts. I have touched on some of the misleading and misunderstood commonly published statistics (third item), which give the illusion that the US and UK medical schemes have common outcomes. They don't. (For more see The Tiger that Isn't, a book about numbers that uses the NHS stats as examples of statistical manipulation.) This post will address the administrative ease for patients of the NHS. Next, I will discuss the myth of free health care. Later, I will discuss some of the inherent weaknesses of the NHS, most notably preventative care. Then, I will turn to the strengths and weaknesses of the US health system. Finally, if the law is still around, I’ll turn to Obamacare.
The Deceptive Ease of Administration
When reading personal accounts of medical experiences in the US and UK, the relative ease of the UK’s NHS jumps out, or more accurately the difficulty of paying health care bills in the US--deductibles, co-pays, collection calls due to hospital bill confusion--shows. Regardless of if money is tight, the process of paying health care bills in the US is not simple.
With the NHS, one doesn’t need to even think about paying. And therein lies the NHS’s greatest strength. It is easy.
Three elements of the NHS make that perception. First, NHS services seem free because the bill is never paid the day you visit the clinic. It is paid though taxes, which are abnormally painless in the UK. Second, since the NHS is a single payor system, one need not bother with choices about insurance or doctors in system. With the NHS, you get what you get. Third, the NHS has a centralized computer system, one that sounds good in theory but has not worked as planned. I will take each point in turn.
Healthcare is paid before and after clinic visits by income taxes, payroll taxes, and VAT. Even though US tax rates are significantly lower, UK taxes are easier to pay. The VAT is a flat 20% addition to most goods and services that is included in the price tag. Sales taxes in the US are added at the till. Few are more than 10%, and those are total rates, state, local, and in some cases reservation. If you are buying something for 10 bucks in Texas, you will need $10.63 when you get to the till. That is, even though the American pays little more than a ¼ of what the Brit paid, the American notices the 6% tax; he has to add it on, consciously think of it. It feels like tipping every time you pay for goods.
Similarly, the PAYE, Pay As You Earn, withholding system in the UK is more comprehensive and accurate than in the US. As a result, few besides employers or the wealthy write checks to HM Revenue and Customs. In short, many people do not feel like they are paying taxes. Hence, when healthcare is not paid for at point of service, it feels free.
Next, since the NHS is a single payer system, it is easy for people to use. When going to an NHS facility, you see whomever you see, provided your visit was routine or minor, you do what needs to be done, get whatever meds your doctor prescribed, and walk out--at least this is how it works in theory. Waiting times are a problem. Prescriptions are a problem. I found that you can only get a prescription written at the hospital filled at the hospital chemist. At the eye hospital--I had a piece of metal in my eye--I did not want to wait in line for the hospital chemist. It was a good hour plus long and I needed to get back to the children. So I took the scrip to my local chemist. I suspected I might have to pay more; I did not know that they weren’t supposed to fill it. It was antibiotic eye creme that they had on hand, so they took pity on me, the newbie American expat, and filled it anyway, mumbling something about NHS kickbacks with meds.
Getting to the hospital or specialist can be a problem too. If you need the ER, you can go directly, but for any other non-emergency problems, you are supposed to see your General Practitioner first. Your GP then has to refer you to a specialist or the hospital. So for instance, with my eye problem, I called the GP first. He had to refer me. You can’t think, “Oh, I have something in my eye, I will call an eye doctor.” Except in an emergency, you need a referral.
So the system is simple if you have basic needs. When your care gets the slightest bit complicated, so does the NHS.
There is a strange letter of introduction, exchange of test results, doctor letter writing dance that goes on with the GP system. This is a bit strange because the UK has a reportedly stellar centralized healthcare computer system. Why all the letter writing and referral dance if they have a database?
Turns out that the health database sounds great, but it is not nearly as effective as advertised. To start, it is susceptible to privacy and accuracy concerns. Ironically Brits seem less concerned with health care privacy issues than Americans* so the privacy issues haven’t killed the system. Worse though, large portions of the database have been lost at least twice since I have been here in London, in 2009, 2007. Here is a short Times summary of the database debacle including discussion of information uploaded without the doctors consent and a cost explosion from £2 billion to £12 billion. UPDATE: They are scrapping the integrated database.
Then there is how the database plays out in an emergency. It is and tad unnerving to arrive at the hospital with a child in visible breathing distress only to have the check in to verify your postcode before any triage. Other than pulling up your centralized data, I am not sure why they ask up front. It appears from the NHS site that an A&E couldn’t turn you away even if you were not standing in your local hospital. Everyone is covered under the NHS, tourists and the like. I guess it is because your postcode determines your medical trust area, and every trust does not cover the same treatments or have the same standards of treatment. Such is the postcode lottery. The NHS isn’t exactly fair. (The guy who exposed the lottery atlas recently died of cancer.)
Next up, the Myth of Free Healthcare.
*I find the relative lax attitude about healthcare privacy bizarre for a society otherwise fiercely protective of their privacy. In my own experience, I’ve found that doctors will discuss patient care with someone not the patient, especially if you are paying the tab. I don’t mean the doctor discussing care of my husband, I mean of other patients, unrelated to me. In the A&E, I’ve seen consultations and treatments in the waiting room conducted at full volume so that everyone knows what everyone else is there for. I can’t explain it. I’ve just noticed it.