
American using Britain’s NHS (2015) - deepaksurti
https://www.businessinsider.in/What-Its-Like-When-Youre-An-American-Using-Britains-NHS/articleshow/46057777.cms
======
oldcynic
As a Brit using the NHS I can only add that I trust, and expect, every
government to make the NHS worse whilst they talk of how marvellous it is.

I would really like it given to an independent cross-party body, or the civil
service, to try distance it from politics and The Treasury. I'd like to see
legislation to heavily penalise drug companies seeking 20,000% price increases
and the like.

Both sides fiddle with it, trivially and constantly. They will even fiddle
when they have won a second term or reorganised ministers - because what they
themselves thought 4 years ago must have been stupid and should be immediately
changed, or something.

Much of the waste is from badly thought through political fiddling, remnants
of previous fiddling, and public-private partnerships stupidly chosen during a
time of lowest borrowing in British history.

Neither side is honest about it however.

~~~
sgt101
Imagine how well an NHS organised as it was in 1948 would function in today's
world. Although there is no doubt that it could be better managed setting it
in aspic will kill it surer than a nail in the back of the head. The NHS will
face massive challenges in the next 30 years from demographic pressure on
demand and staff, technology change and citizen behaviour and expectation.
Radical "fiddling" is going to be needed to keep it alive. This is 100's bn
pounds - it's the core of UK politics and it should be - we are a democracy.

~~~
gaius
Aneurin Bevan believed that the cost of the NHS would reduce over time as the
population got healthier.

The current NHS budget is £125Bn/year. Many people think it is underfunded,
but noone is willing to name a figure for fully funded. Is it £150Bn, 200,
500? No progress will be made, by either party, until someone stands up and
does this.

~~~
jdietrich
>The current NHS budget is £125Bn/year. Many people think it is underfunded,
but noone is willing to name a figure for fully funded. Is it £150Bn, 200,
500?

It's a moving target, because need continues to grow as the population ages.
We're in largely uncharted territory, so it's difficult to make long-term cost
forecasts. You could always find ways of spending money to improve a
healthcare system, so it just doesn't make sense to pick a number ex nihilo.
We do have other, better means of determining what a reasonable level of
healthcare spending might be on a year-to-year basis.

The National Institute for Clinical Excellence have determined a cost-
effectiveness threshold of £30,000 per additional Quality-Adjusted Life Year.
This threshold is a little bit arbitrary, but it's a reasonable rule-of-thumb
as to what treatments provide a net benefit to society. Based on this figure,
we can start to calculate a reasonable overall NHS budget from the bottom-up -
the NHS needs enough money to provide all the healthcare interventions that
NICE has determined to be cost-effective.

In addition to cost-effectiveness, we also have benchmarks in terms of quality
of care. It might not be clinically significant if someone has to wait three
weeks for a GP appointment about their psoriasis or six months for knee
surgery, but it matters to the patient. We know that wait times have been
going up and patient satisfaction is going down, which is a reasonable
indication that the system is underfunded. It wouldn't be reasonable to aim
for instant care and 100% patient satisfaction, but we should at the least
hope for stability rather than regression.

The question of affordability is perfectly fair, but the UK doesn't spend an
exceptional amount on healthcare by the standards of equally-developed
nations. As a proportion of GDP, our spending is roughly average for OECD
nations. In absolute terms, we spend about 25% less per patient than Germany
or Ireland. We can clearly afford to spend a fair bit more before we start
feeling the pinch.

I think that it's perfectly reasonable to spend a few tenths of a percent of
our GDP to try and take the pressure off the system and get the quality
metrics back to where they were in 2015. If costs start spiralling out of
control, then we need to have some difficult conversations about what kind of
care we're going to ration, but I think that conversation is premature if we
haven't first tried a modest increase in spending.

~~~
makomk
Incidentally, one of the provisions in the ACA over in the US specifically
prohibits the use of QALY as a cost-effectiveness threshold. It's just one of
many reasons it's so absurd for Americans to point to the NHS as a
demonstration of how much more cost-effective healthcare would be if it were
nationalised; something like the NHS with its cost-saving measures just
wouldn't be politically viable there.

------
simonbarker87
By comparative metrics to the rest of the world the NHS comes out either top
or pretty damn good. By comparison to whatever the metrics of whatever
government is in power at the time the NHS always looks terrible. Budgets can
be set arbitrarily by the government so it’s easy to make the NHS look like it
is over budget (in fact all you need to do is increase the budget by less than
inflation and talk about absolute numbers to fool the public and hey presto
“the NHS is terribly inefficient”).

The whole “4 hour” thing is mad - you should be seen in a reasonable time
frame for the ailment you have. Severed hand? Go right ahead. Headache and
photo sensitivity that’s been going for a couple of days already? We’ll be
with you when we can and if things get substantially worse come back to the
reception and you may be deemed more critical. Obviously I am over simplifying
the matter but the NHS is staffed by competent trained professionals who
should be allowed to use their own judgment as the whether someone can wait 30
seconds, or 6 hours.

~~~
jdietrich
>By comparative metrics to the rest of the world the NHS comes out either top
or pretty damn good.

Ish. The NHS is remarkably cost-effective, but has relatively poor survival
rates for cancer, stroke and myocardial infarction. International comparisons
seem to damn the NHS with faint praise - it's cheap and the patients are
happy, but it's not very good at keeping people alive.

[http://www.qualitywatch.org.uk/sites/files/qualitywatch/fiel...](http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20International%20comparisons%20%28final%29_disclaimer_update.pdf)

~~~
PaulRobinson
Survival rates for all those things are affected by external factors that are
not in the NHS' control.

Smoking, drinking and obesity are all higher in the UK than in many other
Western countries, and therefore the types and severity of these issues are
likely incomparable.

Compound this with the cultural differences of the NHS (you don't go for a
six-month check-up unless you're elderly, you just see a doctor when you're
already ill), and the fact spending has been prioritised towards other areas
(particularly paediatrics), you start to see a different story.

But there's also the fact the median age of the UK is relatively high. It's so
good at keeping alive in younger years they get older and then develop cancer,
stroke and heart disease/attacks later in life where they might be less
survivable.

We all have to die of something. The NHS can't prevent that. What it can do is
stop you having a lot of those issues earlier in life as in other countries
and therefore the quality of life is improved.

If you want to see an area where it's proper shit, I would not start there: go
with dental work, look at obesity prevention, etc. - that's where it's really
lagging behind many other countries.

------
alyandon
Here in the US I had to take my son (he was 5 years old at the time) to the
emergency room when he had slipped in the bathtub and hit his head which
caused a huge gash right above his eye. We sat in the emergency room for 5
hours before any of the staff bothered to look at his open wound and then
another 4 hours after that before they actually treated him.

The most infuriating part of the experience was the not-so-subtle attempt by
the staff to see whether or not I had told them the truth about how he had
sustained his injury by _constantly_ asking him to recount how he had
sustained his injury instead of actually _treating_ his injury. On top of
that, the staff were rude and generally dismissive when I asked how long they
_thought_ it would be before my son would receive treatment.

And then of course the billing nightmare that ensued was just extra icing on
the cake. The hospital was in network for my insurance (which I verified
before I went and again while I was there) but the staff neglected to tell me
that they were contracted through a completely different company that turns
out was not in network so I ended up having to pay almost $2000 for what
amounted to a few stitches for my son.

~~~
projectileboy
100% f'ing right. People who think the US health care system is fantastic
either (a) haven't used it much, or (b) are rich enough not to care - and in
this category I'll include those with good employer-provided health care
(although this number is dwindling rapidly)

------
foreigner
I am a lot like the author (dual national, lived in both US and UK). One of my
children was born in the US, the other in the UK. I agree with the author
100%. I would emphasize more the peace of mind that in the UK my family's
health care is in no way tied to my job (I earn plenty of money and have never
had trouble finding employment).

There are also huge societal benefits to socialized healthcare. There are far
fewer desperate homeless people in the UK, because many homeless people in the
US are stuck in that situation in large part because of some health issue.
There's just a fundamental feeling in the UK that we're all going through this
life together.

------
new299
"In the UK, I showed up at 9am and was seen instantly"

I don't think that's ever happened to me. Most likely this person was the
first patient of the day, so appointment times haven't slipped yet. 30 minutes
in the minimum I've had to wait in general. I've also had to wait weeks to see
a GP (in the countryside).

I find anecdotal articles like this pretty unhelpful in general. We all have
our own anecdotes, it's more interesting to look at the data. Comparisons
between UK and US healthcare are also somewhat meaningless. They've very
different systems, and their are many other countries with private and public
healthcare systems that you could compare.

~~~
washadjeffmad
I'm not really familiar with NHS processes, so when it took you weeks to be
seen, did someone just take your info when you walked in and say they'd get
back to you when they could, or was your condition evaluated first
(diagnostics run, etc) and an appointment scheduled for you for a particular
date a few weeks in the future?

~~~
jdietrich
The former. Access to the majority of non-emergency care is gatewayed via your
GP (primary care physician/family doctor) - if you need to see a specialist,
you can only do so by asking your GP for a referral. You'll then wait weeks or
months to see a specialist, although you may be sent for tests before then. We
have a chronic shortage of GPs and the system as a whole is severely
underfunded, meaning that many people have to wait weeks just to be seen by a
doctor. The average wait to see a GP is 13 days, but can be much worse in some
areas, especially in winter.

Some GP practices have reduced the strain by offering appointments with Nurse
Practitioners, who can treat common and uncomplicated conditions. This
solution is far from perfect, because there's a lot that Nurse Practitioners
can't treat.

Some patients are just going to a hospital emergency department because they
can't get a GP appointment in a reasonable time frame. This just increases the
strain on the system, because care delivered in an ED is considerably more
expensive. The four hour target is actively counterproductive; When ED
managers are faced with a waiting room full of people with coughs, rashes and
sprained ankles, they are forced to choose between prioritising clinical need
or hitting their targets.

[http://www.pulsetoday.co.uk/your-practice/practice-
topics/ac...](http://www.pulsetoday.co.uk/your-practice/practice-
topics/access/average-gp-waiting-times-remain-at-two-weeks-despite-rescue-
measures/20034534.article)

~~~
Scoundreller
> Some GP practices have reduced the strain by offering appointments with
> Nurse Practitioners, who can treat common and uncomplicated conditions. This
> solution is far from perfect, because there's a lot that Nurse Practitioners
> can't treat.

Are the NPs not permitted to treat these other conditions, or incapable? I
fear there's a turf war between GPs and NPs, where GPs are worried about
losing bread-and-butter work that takes little time but accounts for a large
number of visits.

~~~
jdietrich
>Are the NPs not permitted to treat these other conditions, or incapable?

Both. They're cheaper because they've received much less training than a GP.
We could allow them to treat a wider range of conditions, but there would be
serious patient safety implications.

The use of nurse practitioners in primary care is relatively new and we don't
have a lot of good-quality evidence on patient outcomes, so it's reasonable to
act with some caution until we have better evidence. Even in their current
role, they could be missing significant clinical issues that a doctor would
have spotted - we just don't know at this stage. The concern isn't about the
99% of patients who have something mundane, but the 1% of patients who have
something that looks mundane but is actually very serious.

There's undoubtedly some amount of territoriality on the part of doctors, but
at the moment everyone is just desperately trying to cope with demand. There
seems to be fairly good esprit de corps throughout the NHS, with practitioners
at all levels uniting around the need to maintain good patient care against
the common enemy of Jeremy Hunt.

------
peckrob
Overall this is a great compare and constrast article, but I do have one
quibble with it.

> _In the US, I 've always been able to see a specialist within a few days.
> Score one for America._

This is really, _really_ heavily dependent on where you live and the number of
doctors and specialist doctors in the area.

I live in a mid-sized city. If I need to see a typical general practice doctor
for a routine problem (coughs, etc.) I can usually be seen the same day, but
I'll probably have to wait a 2-4 hours depending on when I go.

But if I need to see a specialist (allergist, dermatologist, sleep doctor,
etc) and it's not a life-or-death emergency, it's usually a six-week to six
_month_ wait for an opening. It literally took six months before I was able to
see a dermatologist last year.

My only other option is to drive 2 hours away to the next (bigger) city that
has a medical school and a large concentration of doctors. Sometimes you can
get an appointment in a few days if you're willing to drive. This is actually
what I've started doing when I'm referred to a specialist.

And if you live in a rural area, even routine medical care can be difficult to
come by. Many towns will have a small clinic staffed by a doctor who lives in
the community, but often this doctor may have rounds where he covers several
communities in a geographic area. So, for instance, he may only be in the
office in your nearest town Mondays and Thursdays. So if you need to see a
doctor and the local nurses can't handle it, you either have to wait or drive
to wherever the doctor is that day.

Where I grew up in East Tennessee, we also had a volunteer service called
Remote Area Medical [0], which provided free service to very remote areas of
Appalachia. I remember going to the Knoxville airport with my Dad once and
seeing their DC-3 fueling up for its next trip.

[0] [https://ramusa.org/](https://ramusa.org/)

------
tomalpha
So how does the US improve its healthcare system?

More interestingly, can the US political system ever enable an evidence-based
debate around it?

From the other side of the pond, it feels like debates end up being emotional
rather than scientific.

(I’m a Brit and love the NHS with a passion but would not claim that it’s
without flaw. Neither would I claim that we necessarily have more reasoned
debates about issues here...)

~~~
grecy
> _More interestingly, can the US political system ever enable an evidence-
> based debate around it?_

I honestly think the reason the US is slipping so much is because their
political system never seems to have evidence-based debates around anything.

Worse, they have absolutely no interest what-so-ever in comparing their
country and how it's actually functioning to other Developed Countries for the
purposes of improvement. In fact, I genuinely don't think they care to improve
anything, at all.

~~~
DFHippie
Funny how you you complain about evidence-based debates proceed to
mischaracterize the U.S. based on your impressions.

Americans are not all of the same opinion. They do not all use the same
arguments which have the same faults. In this they are like all people
everywhere. Also, their political parties do not all employ the same arguments
with the same faults. Arguing that everyone has the same faults is both-
siderism. It is a counsel of despair. In fact, each party will use facts and
international comparisons when doing so supports their preferred policy.

The Democrats have been quite fond of international comparisons in support of
their efforts to improve healthcare. I struggle to find a topic on which
Republicans prefer facts to mythology but they certainly grab onto a fact when
it supports what they want to do. They can recognize and employ a good
argument if it presents itself.

If you hear someone making a stupid argument, regarding health care or
whatever, nine times out of ten it is not because they desire a worthy thing
and are too stupid to get it but because they desire an unworthy thing and are
crafty enough to recognize a plausible cover story. You can recognize this
happening when someone drives for a constant goal but changes arguments as
suits the moment. Republican arguments for lowering taxes fit this pattern as
do arguments for not doing anything about climate change.

It isn't the stupidity of politicians, or even their voters, that explain
American policy. It's disharmony within the nation mixed with political
institutions that expect people to work toward a common purpose.

------
CasaDeTony
As I'm also an American using Britain's NHS, I was pleasantly surprised to see
the article mostly matches up with my experiences using local services (though
as others have called out, NHS GPs and Specialists still have regular 15-30
minute delays for pre-scheduled appointments, IME)

The only downside I would call out is that I pay slightly higher taxes in the
UK than I would in the US, and I imagine that part of it goes to fund NHS
programs.

That said, the small increase is a relative bargain, given the the excellent
level of care provided by NHS staff and the avoidance of insurance nightmares
I was used to dealing with back in the states.

~~~
DanBC
I'm not sure how it factors into taxes, but the US government spends more per
capita on healthcare than the UK government does.

[https://visual.ons.gov.uk/how-does-uk-healthcare-spending-
co...](https://visual.ons.gov.uk/how-does-uk-healthcare-spending-compare-
internationally/)

------
decasia
As a point of anecdata, my dad, an American, lived in Wales the last ten years
of his life. His arthritis got too bad for him to work, and the NHS took
excellent care of him for years. Then he had cardiac issues and although his
NHS doctor recommended heart surgery, they didn't schedule the procedure for
several months and he died of a heart attack in the meantime (age 62).

Public healthcare took great care of him and then it killed him. Hard not to
be ambivalent about that (though n.b. this is not an endorsement of the US
system by any means).

------
Havoc
>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.

That is so bizarre. I'd be concerned if it takes and hour. Seriously it's
called emergency room because it's an emergency, not a "it can totally wait"
room.

~~~
dominotw
My friend had a seizure while we were on a business trip in a suburb of
London. We were taken to the hospital in ambulance, I remember we had to go
through a series of 6 rooms each getting progressively smaller( first one had
like 200-300 ppl) and less people. Took us about 5 hrs to get to the doctor.
Doctor was patient and polite.

------
bane
Might be of interest to discuss other systems as well. I'm somewhat familiar
with the system in South Korea:

\- There's a National Insurance System that all citizens are signed up to at
birth.

\- Premiums are based on income with employers splitting the cost 50:50. Low
income/unemployed people go on a slightly different but substantially similar
plan with no premiums.

\- Prices for procedures are nationally set and fixed.

\- Hospitals and Doctors are generally private, but must accept the National
Insurance.

\- Patients pay a co-pay and doctors bill the National Insurance system for
the full price.

\- The National Insurance plan only covers a set of elective procedures.
Unelective procedures are payed for out of pocket, or by private supplementary
insurance (which are also quite popular). e.g. if you have cancer you can go
with the prescribed National Insurance treatment and it's covered, or you can
go with other treatments which the private hospitals are more than happy to
provide.

\- Upside: people go to the doctor early and often and as a result South Korea
has some of the best medical outcomes in the world (with a few exceptions).
The robust private hospital system brings in medical tourists for a wide
variety of medical procedures at low prices. If you're in the Hospital and
want better care than the National Insurance covers, and you have the money,
your class of care options is virtually unlimited. Fewer bankruptcies than the
U.S. and <7% of GDP is spent on healthcare. System is considered among the
best in the world.

\- Downside: The system tends to favor simpler problems that can be handled in
an assembly-line fashion. Doctors need to see huge numbers of patients to make
a living, so bedside chat time is very limited (but in practice it's about as
much time as I see my doctor in the U.S.). Doctors over recommend procedures
and tests to get the insurance money.

\- Paradox: Because doctors are payed per procedure, but the procedures are
limited, they tend to oversubscribe labs and imaging. This means that there
are about 3x as many hospital beds and imaging machines than the U.S.

\- Source: Visit South Korea semi-frequently, been sick there. Even not being
insured (thus paying out of pocket) the cost was far lower than my insured
care in the U.S.

------
pjc50
Note that the UK _also_ has a small private system; if you're really not happy
with waiting for appointments or operations you can pay to be seen. Some
higher-paid jobs come with health insurance, which is really cheap because
anything difficult or expensive can be shunted off to the NHS.

------
mocopoco
The NHS will try many things to avoid expensive options like MRIs and more
expensive medications.

For Multiple Sclerosis I was given one MRI and NO medications over the course
of 12 years as I went from relapsing remitting to secondary progressive. Total
postcode lottery so fuck the NHS.

------
sambe
I have never seen such a bureaucratic/inefficiently operated institution - and
there are plenty to choose from in the UK. My electricity company replaced all
Vs with Ks in letters to us for 7 months. The NHS is much worse (try even
getting a letter to arrive within a month - to the right address - let alone
receive any medical treatment).

I have not dealt with US healthcare but having experienced other countries'
I'd strongly suggest not following the UK system - other European countries
certainly come to mind as working substantially better. Of course, there's a
huge "Save Our NHS" push due to the number of people it employs, unions,
misplaced national pride etc.

~~~
arseraptor
Funny how your anecdotal point is just that, anecdotal. Here's another
anecdotal point for you -- Pancreatic cancer (stage 2). Diagnosed on the first
visit even though a private doctor had missed it previously. Surgery in less
than 5 days, excellent follow-up and post-surgery care including the surgeon
having a set of non-mandatory procedures approved in record time (10mins) as a
preventative step towards recurrence. Two years later, cancer free with
excellent reminders and follow-ups on periodic checkups.

Your experience does not dictate the system, as doesn't mine.

~~~
vixen99
So instead look at the statistics. In many sectors they are dire.

~~~
Scoundreller
UK residents have the 20th highest life expectancy in the world. 21st for
health-adjusted life expectancy. The Japanese take the top spot and live +2
years. The average American lives -2 years.

There's a lot more to health than the health care system, and this doesn't say
much about how painful the process can be, but the stats look pretty good for
the UK.

[https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...](https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy)

~~~
lttlrck
But how much of life expectancy can be attributed to the healthcare system?
Maybe Brits spend more time outside, and are less stressed, etc etc. how have
the rankings changed over time and what changes in the healthcare systems
correlate to those trends?

------
madman2890
> Fifteen minutes to see a free doctor! It's not free, the money to pay the
> hospital bills comes from taxation

------
triviatise
one of the meta challenges with socialized medicine is that there is virtually
no innovation due to price controls (please no anecdotes). The US essentially
funds medical innovation for the entire rest of the world. If the US goes
socialized you will see almost a complete halt to medical innovation over
time.

Here are 3 (not evidence based) reasons why medical care costs more in the US:

1) more administration (too many rules/regulations) 2) higher costs for the
base goods (people get paid more, pharma, medical devices, etc) due to lack of
price controls 3) people get more care, potentially even when it isnt going to
help

[https://www.pbs.org/newshour/nation/why-does-health-care-
cos...](https://www.pbs.org/newshour/nation/why-does-health-care-cost-so-much-
in-america-ask-harvards-david-cutler)

~~~
UseStrict
I strongly disagree with your first statement. The US definitely has a high
rate of innovation in medical procedures, but by no means is it Atlas,
carrying the world on its shoulders. Canada which is just a single socialized
healthcare system has systematically produced fantastic innovations in drugs
and therapy over the last 100 years. We have dozens of research hospitals who
innovate regularly. I don't have the time to spend researching every single
innovation, but a small sample is included below.

There is a lot of donor money and government grant money in medical research
around the world.

Research Hospitals (off the top of my head)

\- The Ottawa Hospital

\- SickKids

\- Sunnybrook Health Sciences Centre

\- Sinai Health System

\- Kingston General Hospital

Innovation

[1]
[http://innovativemedicines.ca/medicines/timeline/](http://innovativemedicines.ca/medicines/timeline/)

[2] [https://legionmagazine.com/en/2009/08/eight-great-
canadian-m...](https://legionmagazine.com/en/2009/08/eight-great-canadian-
medical-breakthroughs/)

~~~
caseymarquis
This is even untrue in the US. My SO works at a system of donation/endowment
funded US charity hospitals where they have a history of inventing new more
effective methods of treatment. Some doctors will take less money to work in
an environment focused on positive patient outcomes instead of performance
metrics tied to profit.

