By Jim Edwards
Business Insider, Jan. 29, 2015
I’ve spent half my life in the US and half of it in the UK, so I’m used to both countries’ healthcare systems. I recently returned to London after 20 years in America, and after a few doctors’ appointments I’ve come to see the NHS through American eyes.
The National Health Service is, as all Americans know and fear, a completely public “socialized medicine” system. It’s dramatically different from the US’s patchwork system of private providers and insurance companies.
My story isn’t representative, of course. Healthcare delivery is different in the UK depending on where you live and which doctors and hospitals you use — just as it is in the US. But I’ve now used both systems for about two decades each, so I feel I have a pretty good handle on the main contrasts.
‘This Rolls Royce isn’t moving fast enough!’
The context here is that the NHS just released its most recent stats on accident and emergency room waiting times. The headline number is that 84% of patients are seen within four hours. In the UK, this is regarded as a huge failure — the standard the NHS is supposed to meet is 95% of patients in four hours. The UK media went into a fury about it, and some hospitals have begun postponing and rescheduling some non-emergency procedures in order to get those waiting times down.
In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle. Bear in mind that within that four-hour period the NHS doctors are triaging patients: If you get hit by a bus, you’re going to see someone instantly. If you broke a finger because you fell over while drunk at the pub, you’re probably going to wait at the back of the line. It’s not like people are literally bleeding to death while they wait for attention (although the British media loves it when it finds individual cases where that has happened).
So my overall impression is that currently, the Brits’ complaints that the NHS isn’t hitting that 95% mark is akin to saying, “This Rolls Royce isn’t moving fast enough!”
Show up when you’re told to — or else
The first major difference from the patient’s point of view is what happens when you call your doctor for a routine appointment. My specific health issue was that I thought I was going slightly deaf, and wanted it checked out.
I’m a dual US/UK citizen, so I qualify for NHS treatment. Here’s what happened to me.
In America, you call your doctor and request an appointment when it’s convenient for you. They might ask you what’s wrong with you, presumably to make sure it’s not something that requires immediate treatment. But basically, it’s first come, first served, regardless of how important it is. Usually, you can pick an appointment time that’s convenient for you if it is not an emergency.
In the UK, I was given an appointment whether I liked it or not. I called and leave a message. Within an hour or two a nurse practitioner called me back and asked me a few questions about my problem over the phone. (You’ve got to take the call in a private place if you don’t want your office mates to hear.) Then they said: Come in at 9am on Thursday. There was no choice over appointment times — the assumption is that if you’re ill, you’re going to come to the doctor when they say.
At first I found this jarring. In America, I get to choose when I see the doctor! In Britain, I better show up when I’m told. But the appointment came quickly, as the local health authority in London has targets it needs to meet. Ultimately, I saw the logic of it: This is a public health system. It needs to manage its costs and services. If you’re really sick, you’ll show up. If you only want to show up when it’s convenient for your schedule, then how sick are you, really?
America is worse at on-the-day care
In America, I’ve always had a long wait to see my doctor. I have read many a back issue of Newsweek in my primary care / general practitioner (GP) doctor’s office. I’ve sat there for an hour playing with my phone while the doc sees patients in the order they were booked.
In the UK, I showed up at 9am and was seen instantly, at the Waterloo Health Centre. For an American, this was bizarre: My butt barely touched the seat in the waiting room before my name was called. Turns out my doc and her staff are serious about patient scheduling.
This was one reason I became convinced that the NHS way of scheduling is superior: You might not get the time or date that you want, but once you’re in, you get seen super-quick.
The NHS actively discourages some patients — for good reason
The NHS actively discourages some types of patients: Interestingly, NHS offices and hospitals have posters up all over the place warning you not to show up at the emergency room if you have a cold or the flu. They’re actively discouraging patients with minor ailments from seeking emergency treatment, and trying to get them to see their regular doctors instead. It’s sensible — everyone knows that a vast amount of hospital time and money is wasted treating people who are not an emergency. And hospitals and doctor’s surgery waiting rooms are a hotbed of germs. But still, it’s a culture shock to see a medical institution put up signs that basically say, “go home, you idiot!” in every waiting room.
The US never discourages patients from doing anything. I’ve never seen any kind of public campaign to persuade patients to apply some common sense before dropping themselves off at an emergency room. The entire US pharmaceutical industry is also dedicated to running ads encouraging people to “go see your doctor” for even the most trivial of conditions.
The treatment from my primary care GP was the same in the UK as it was in the US. I’ve had great care from 95% of doctors I’ve ever seen in both the US and the UK. Doctors are doctors. They’re mostly really nice and good at what they do. The system that pays them doesn’t seem to make them better or worse.
There is basically no paperwork with the NHS
There is a load of paperwork for patients in the US. This is easily the worst aspect of US healthcare — the billing paperwork. If you’ve ever had any health issue that required more than a simple doctor visit, you will know that it precipitates a seemingly never-ending series of forms, bills, and letters. You can be paying bills months, years later. And it’s almost impossible to correct a billing error. It’s stressful. I developed an intense hatred for health insurance companies in the US because of this.
There was close to zero paperwork in the NHS. I filled in a form telling my doc who I was and where I lived, and that was pretty much it. The only other paperwork I got was a letter in the mail reminding me of my next appointment. They sent me a text reminder, too, which no American doc has ever done. It was incredibly refreshing.
The standard of care is the same
So, was I going deaf? Maybe. Maybe not. I’d lost my sense of balance in summer 2014, which an American doctor had diagnosed as Benign Paroxysmal Positional Vertigo. It’s a condition of the inner ear. It made my body feel slightly drunk and clumsy even though I am completely sober.
The US doc told me there is no treatment and it goes away on its own, mostly. A lot of people get it, apparently. I was managing fine and it doesn’t bother me, anyway.
The UK doc told me the same thing, but also suggested I might have Meniere’s Disease, and wanted to send me to a specialist to get it checked out. Meniere’s isn’t really a disease, it’s just a collection of symptoms: dizziness, hearing loss and a ringing in the ears. Again, there is no treatment. But it’s rare.
This freaked me out a little bit. I was used to the US system which is heavily “defensive.” Doctors tend to over-treat patients because they get sued if they miss something. They also get paid more money for doing more work. Yet it was the NHS doctor that suggested extra treatment.
It was going to be free — so I said yes!
A long wait for NHS treatment …
I then made an appointment with a specialist at the Guy’s and St Thomas’ Hospital in London.
In the US, I’ve always been able to see a specialist within a few days. Score one for America.
In the UK, they said “we’ll see you in January.” It was late November, six weeks or more away. This was a shock. I was going deaf now — not in six weeks! What the hell?!
NHS waiting times are a real thing, it turns out. I comforted myself with the assumption that the staff had made a decision that my condition was likely not life- or health-threatening, and had moved me to the back of the line. It was frustrating. Ultimately, I also needed to change my appointment because I had to leave the country on business, and this was quite difficult to do. I had to call a few times, basically to catch the hospital booking staff at the right time of day, in order to do it. I wished Guy’s and St. Thomas’ had an online system for this, but they don’t — just a bunch of people answering phones, most of whom don’t have access to the right appointment schedule.
It was that appointment system again: You’re booked in according to their priority, not yours. The big lesson with the NHS is, it’s a lot easier to just show up when you’re told.
Old people in Britain are really rude
In the US, I expect to wait up to an hour in the specialist’s waiting room on the day of my appointment. I often wonder if Time and Newsweek were such big magazines in the US because they’re needed for bored patients in American doctors’ waiting rooms. Nothing ever happens promptly on the day in US healthcare, as far as I can tell.
In the NHS, again, I waited only a couple of minutes. Credit to the staff at St. Thomas, they are cranking through their patients.
On two occasions I noticed old people complaining angrily (and rudely) to the office staff that they had been made to wait 15 or 20 minutes to see their doctor. As an American, I almost laughed out loud. Fifteen minutes to see a free doctor! This Rolls Royce isn’t moving fast enough! I asked a British friend — someone who has ongoing health issues and sees a lot of doctors — if old people complaining like this was common. Turns out, it is. Old British people love to complain to NHS staff if they wait more than 1o minutes. Everyone just expects their appointments to be exactly on time.
Again, the NHS care was great. I saw two different doctors within an hour, one for testing and one for diagnosing. A third admin staffer was coordinating the lists so there was no doctor downtime. It was like being in a highly efficient factory. It looked like hard work. I could tell that one of my doctors was not interested in chatting. She treated me, and wanted me out the door. There was a bunch of patients behind me, after all. In America, docs seem to be happy to chat as long as you want — and you can tell that extra couple of minutes with each patient creates long delays as the day wears on.
The good news: I am not going deaf! I have great hearing, it turns out. They even showed me a chart of it. But the tinnitus — ringing in my ears that started years ago because I used to go to a lot of punk rock gigs in my youth — has gotten worse, making me feel more deaf.
The UK NHS specialist said she was 99% sure there was nothing wrong with me, or at least nothing that could be treated, but she recommended an MRI to see what the condition of my inner ears is like. This was reassuring. In no way was my treatment rationed or denied, the way Americans fear. It was just the same as in the US, with the same number of docs and the same level of high-tech equipment.
The cost to the patient is much cheaper in the UK, obviously
So how much did all this NHS care cost me? £0. Nothing. Zero. I paid not a penny for some top-notch healthcare. There is no such thing as a “free,” of course, but the per-capita cost of healthcare in the UK (paid by the government via tax collections) is generally lower than the US, according to the World Health Organization. Americans spend $8,362 per capita on healthcare annually, the Brits spend $3,480. Here is a breakdown:
Doctor visit: £0
Diagnostic test: £0
Typical US prices*
Doctor visit: $100
Hearing test: $72
Total: $1,372 (Total payable by the patient in cash, or typically 90% from insurance and 10% as a patient copay. Prices taken from Healthcare Bluebook.)
Sorry America, but NHS treatment really is better over all
The bottom line: I prefer the NHS to the American private system. It’s a little more inconvenient in terms of appointment times, but due to the fact that it is free, has no paperwork, and the treatment on the day is super-fast, the NHS wins. That Rolls Royce is moving at a pretty decent clip.
And, of course, there is the small matter of the fact that the NHS covers everyone equally, whereas Americans get care based on their ability to pay, leaving tens of millions with only minimal access to care. (Obamacare is changing that, but it’s leagues behind the NHS if you’re comparing them by the standard of universal full-service coverage.)
Americans think they have the best healthcare in the world. Take it from me, a fellow American: They don’t.