I work as doctor in one of the most monolithic healthcare systems there is. The UK NHS is centrally funded from general taxation and is the third largest employer in the world. Hospitals are mostly owned by the government and doctors and other healthcare workers in hospitals are effectively civil servants. Family doctors on the other hand are effectively private contractors for the state.
The aim is to provide “cradle to grave” healthcare for all UK citizens and legal residents, free at the point of need. The only charges are flat rate prescription charges which are waived if you are on a low income, under 18, or have a chronic condition like diabetes which means you will need a lot of repeat medications. And of course the legalised extortion racket that is hospital parking charges.
That’s right, you can walk into an ER with a broken leg, get a kidney transplant or waste my time with your self-limiting viral illness and not pay a penny (or dime if you prefer).
Sometimes the quality of care provided is truly exceptional, and sometimes, well, less so. I’d like to talk about the good, the bad and the ugly.
Particularly for acute problems, like heart attacks, the care you can get is truly world class. If your coronary arteries give up on you after a lifetime of nicotine and saturated fat you can be on the slab getting angiography to unblock them in 20 minutes or less, with no questions about payment. And this care is available to you whether or not you are a big shot banker in the City of London or something more socially useful like an alcoholic bum who sleeps in the park.
There is no co-pay (apart from – and I have no doubt you guys will find this hilarious – for dentistry), no lifetime limits, and you are not tied to your employer for healthcare. You don’t have to save up in order to be able to pay to deliver a child, and you aren’t going to go bankrupt because you can’t pay for your chemo.
The NHS has exceptionally strong primary care. NHS general practitioners (GPs) are a bit like the family doctors in the US. They provide excellent general healthcare and manage most conditions. If you need to see a specialist like me it is they who refer. This triage is hugely efficient and cuts down on unnecessary activity in the secondary care sector. The upshot of this, and perceived downside for many, is that patients cannot see a specialist directly (more on that later).
One of the less tangible benefits, and one that I personally find satisfying, is that I have no pecuniary interest in my patient’s care. Have the scan or not, get the expensive treatment or not, have me do the procedure or not – it makes no financial difference to me. This disinterest, in the purest sense of the word, means that people trust me to make the right decisions and offer them treatments that are best for them, and not my bank balance.
It is free. Did I mention that it is free? Of course, if you fancy going to a private hospital with lovely carpets and better food but much worse care then you can get private health insurance.
It is free. While that means anyone can access it, it also means that anyone can access it. Some people don’t always value what they don’t pay for and think it is perfectly ok not to attend booked appointments, or turn up to the ER at 2am on a Friday night with the same back pain that they have had for 25 years (to anyone thinking of doing this – I don’t think I am going to have any better ideas than the succession of doctors and reiki masters you have seen over the years, and someone is probably doing their best to die on me not very far from where you are sitting. Stay at home!).
If your problem is not life-threatening, you will wait to see a specialist – longer than you and perhaps they would like. As real terms funding has been going down (despite what the politicians would have you believe), that wait will get longer.
For some, the fact that GPs are effectively the gatekeepers to specialist care is a problem, and certainly one that patients can find frustrating. Personally, I think the person with the medical degree and decades of experience is better placed than you to decide whether or not you need to see a gastroenterologist for that abdominal pain, but, you know, whatever.
Continuing in the vein of cost, some very expensive treatments, particularly newer cancer drugs (which it has to be said are in the main expensive with dubious survival benefits at present), are simply not available to NHS patients. As funding cuts bite this is becoming increasingly problematic and it is currently the case that some high-cost cancer treatments that are standard of care in other countries are not offered to NHS patients. NICE is a body which aims to promote cost and clinical effectiveness in the NHS and it is this organisation that decides whether or not treatments should be offered (the ins and outs and rights and wrongs of all this are a whole article in itself). This is obviously highly controversial and some treatments are simply being rationed due to their high costs, for example the newer treatments for Hepatitis C.
It all comes down to money at the end of the day. We spend less as a percentage of GDP than other developed nations, and the fact that the NHS can provide care that is sometimes as good, sometimes worse, and sometimes better, but is definitely in the mix, when compared to these countries is a testament to the staff working within it. But as costs rise and funding falls, there will be a reckoning.
Cuts in social care mean that often there is nowhere safe for patients to be discharged to, particularly the frail elderly. They linger in hospital unnecessarily, waiting for care to be arranged while we all hope they don’t catch pneumonia and die. This happens on a distressingly regular basis.
Raising taxes to pay for the resources needed is, as ever, politically toxic. While perhaps insurance-based “top-ups” could relieve things somewhat, they remain iniquitous and it is difficult to see how they will integrate with the NHS as it currently exists. More worrying perhaps is that our political masters look not across the English Channel to our European neighbours for models of care but across the Atlantic to the catastrophe that is the US healthcare system.
So where does that leave us? The NHS remains a towering achievement whose future is uncertain, but I am deeply proud to work for an institution that still aims to provide free healthcare for all as a fundamental right, and puts these ideals into practice every day. Health policy is often made by people working in think tanks in their 30’s or 40’s who often have no direct experience of being unwell. As Susan Sontag so memorably put it, we have no idea what it is like in the “Kingdom of the Sick” until we are there. The patients I see with serious illnesses, both chronic and acute, hugely value and appreciate the universal healthcare that they are provided. It is such a precious and important gift to be able to give – to relieve suffering, to cure diseases and sometimes even to save a life. To be able to do so freely considering only a patient’s clinical need and not their financial situation is a wonderful privilege, and I cannot imagine it any other way.