An American doctor’s experience with the NHS

You know it’s going to be one of those days when one of the first tweets on vacation inquires about the closest hospital.

Victor, one of my 11-year-olds, had something in his eye courtesy of a big gust of wind outside of Westminster Abbey. He was complaining enough to let me flip his eyelid and irrigate his eye on the square in front of Big Ben. (I’m sure several people thought I was torturing him.)  Despite an extensive search and rinse mission no object or relief was to be found. I fretted about going to the hospital. It wasn’t the prospect of navigating a slightly foreign ER, but simply the prospect of the wait. While I am a staunch supporter of the British NHS in the back of my mind I envisioned a paralyzingly full emergency room and an agonizing 18-hour wait only to find he had nothing in his eye (the basic antechamber of hell scenario). To ensure we really needed to go I gave Victor a choice between the emergency room and a toy store (Gunter’s 3rd rule), but he declined the toys so off we went to St. Thomas hospital, conveniently right over the bridge.

The hospital was on the aging side and a little drab, but clean and well-marked. I didn’t have to ask anyone for directions. We had to take a number to be registered, but waited less than 5 minutes. I gritted my teeth a bit in preparation for the we-are-not-from-the-U.K. conversation, but it wasn’t an issue at all. I offered my U.S. insurance number for billing, but was told they didn’t need it. The clerk was, however, impressed with the fact that I flipped his eyelid and irrigated his eye before coming. “Well, you did all the right things,” and looking at his red and watering eye she smiled and said. “Looks like you are in the right place.”

Registration completed, we waited to be seen by the children’s part of the ER. A registrar (resident) did a quick triage within 5 minutes of our registering (also impressed with the eye irrigation) and then a nurse did his vitals and took a history. After that we waited less than 15 minutes for the registrar to do a formal assessment. He wanted ophthalmology to do the evaluation. I was a bit surprised the ER doc wouldn’t do it, but every facility is different and when they found out that Victor was born at 26 weeks and had retinopathy of prematurity they got a bit jumpy. Everyone does. I was OK with ophthalmology checking him out. What I have learned from years of medicine is don’t mess with the local order.

We were walked over to the urgent care clinic and were warned that the ophthalmology registrar was covering the whole hospital so it might be a while. This was our longest wait, about 20 to 30 minutes. She was very nice (also working on her PhD). Dr. Katie Williams (she gave me permission to use her name) diagnosed Victor with a corneal abrasion and easily snagged the offending speck of dirt wedged under his eyelid.  Once removed Victor exclaimed, “It’s gone!” and within a minute or two the redness cleared up. She put in antibiotic ointment and gave us a tube to use at home.

“So where do I pay?” I asked Dr. Williams.

The answer: You don’t. Perhaps they might bill us, she just wasn’t sure.

I was about as dumfounded at her answer as she was at my asking.

I protested that it wasn’t fair. We had used services and I was very prepared to pay. I also have insurance that covers emergencies when out of network, so I was pretty sure I would be reimbursed at least some of the visit. However, we were just sent away. They do have my address so it is possible I will get a bill in the mail.

I am very curious what similar care would have cost in the U.S. The saddest commentary of all is that it is really impossible to tell as billing practices are so bizarre and opaque. My guess is it would be a minimum of $1,000 in America for cash (which is egregious). If I ever get a bill from the U.K., I’ll post a follow-up. If anyone has had similar care in the U.S. and received a bill please do post in the comments. You can remain anonymous if you like.

But what of this idea that national health care means DMV-purgatory worthy waits, Dementor-staffed death panels, Saxon-age medical equipment, and incompetent care? Well, I can tell you we had great care at St. Thomas and Dr. Williams was fantastic. The slit lamp wasn’t brand new, but it worked just fine. Sure it’s an n of one, but I’ve been to the ER more times than I can count with my other son and this was as smooth as the best care we’ve had in the United States.

We could have hit the ER at an opportune time, but to expand my n I’ve also asked many people about their medical care while I’ve been in the U.K. Not one person wanted to abandon the NHS. I’ve heard of excellent care and some care that was lacking, but the bad care has nothing to do with the “national” part. Rather it was diagnostic errors or a full hospice unit, things that I hear about with the same incidence back in the world of commercial insurance. Take away the accents and I could easily have been listening to a group of Americans discussing their care. With one exception, no one in the U.K. is left wondering what the price will be or gets an egregious bill.

It makes you wonder exactly what frightens Americans about the NHS?

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • QQQ

    “It makes you wonder exactly what frightens Americans about the NHS?”

    “no one in the U.K. is left wondering what the price will be or gets an egregious bill.”
    ————————————————————————————-

    I think the founders understood human nature the best they could. Human nature wants everything free, but that’s not reality so the country was founded as a republic and not a socialist state. They warned about the tyranny that could manifest by giving the government to much power. The original design was individual accountability, letting people keep their own money, then slowly things changed, income tax, social security, welfare, and healthcare all abused and corrupted by big government. The founders understood the best person to take care of you was you –necessity is always the mother of invention.

  • James O’Brien, M.D.

    “no one in the U.K. is left wondering what the price will be or gets an egregious bill.”

    And what happens to the supply demand curve when people expect that?

    If everyone got food for free, what would happen to the cost of food?

    It’s interesting that you see that as a good thing where I see it as one of the main causes of the health care inflation problem. And the eventual cause of the bankruptcy of Medicare.

    If you think everyone is happy with NHS, you need to watch Prime Minister’s Questions.

    • Lisa

      The NHS is tax supported; medical care in England is not free. I don’t think the point of the article is that her son’s care was free, rather that the system worked reasonably well for her son and that the scare stories about NHS and universal coverage are exaggerated by those who are opposed to to tax financed health care.

      • James O’Brien, M.D.

        It was paid for by British citizens who probably make about an eighth of what she does…and she could have afforded private clinic which is available in Britain…but no worries at all about the reverse Robin Hood ethics of the whole transaction….it should bother supporters of NHS more than opponents

        Ironically the article illustrates why programs like the NHS are doomed…

        • Lisa

          I think most people in Mexico couldn’t have afforded the clinic you went to.

          The article is you posted a link to doesn’t illustrate that the NHS is doomed; it seems to me that the article mentioned steps that are being taken to correct the problem of ‘medical tourism.’

          England is not a poor country; I think the per capita GDP is about 20th in the world; the US is 6th. Funny that England can afford a tax financed health system and we can’t.

          • James O’Brien, M.D.

            20th in the world isn’t that good compared to what we have, and facts are stubborn things. You can argue all you want but they aren’t as wealthy as we are:

            From that right wing rag, the Washington Post:

            http://www.washingtonpost.com/blogs/govbeat/wp/2014/08/26/if-the-uk-was-a-u-s-state-it-would-be-the-second-poorest-behind-alabama-and-before-mississippi/

            Cruise ships charge you to use medical service and then you can submit to your carrier.

            I think the good citizens of Engiand at least deserve a bill to the carrier to compensate for their generosity..

          • Lisa

            I didn’t say you were a bad guy that you paid out of pocket for medical care in Mexico – I just pointed out that it was probably unaffordable to man people in Mexico.

            I have no problem with the NHS correcting the problem of ‘medical tourism’ and I would have had no problem with the NHS billing the OP. But I still think the point of the article wan’t that the OP got didn’t have to pay, but the care her son got was good. All that you hear from US politicians is the NHS is awful. I think the truth is close to this: the NHS has problems (like any medical system, including ours) but English citizens don’t want to abolish it.

            If a country that is less wealthy than we are can provide universal medical care to its citizens, we should be able to.

          • James O’Brien, M.D.

            Well if we keep doing what we’re doing we will be just another poor country like England that was once great.

            Meanwhile, because they are drifting into poverty, lifespans in the Northwest are decreasing.

            http://www.economist.com/node/21562938

            I’m not opposed to universal emergency or catastrophic care, which in America we had on a de facto basis though it was a sloppy system. What I am opposed to is universal comprehensive health insurance that will bankrupt us because there is no disincentive to breaking the bank. Witness the explosion in Medicare costs well beyond predictions.

            You can talk about utopia all you want, someone responsible eventually has to look at the numbers.

          • Lisa

            I think this country got to be ‘rich’ through a government that favors business and therefore the wealthy; look at the hugh disparity of wealth in this country.

            The article you linked to suggest that the lifespans in the English Northwest are decreasing across the economic spectrum. And it does not suggest in anyway that the NHS is responsible for the economic decline in the area (which is uneven).

            I am looking at the numbers. We spend more on medical care, with relatively poor results. Single payer health care will not bankrupt us; I think it is the only way to remove the major reason health care costs have increased so much in the US which is the profits to be made by corp med and the pharmaceutical companies.

            Medicare costs are not exploding:

            http://www.nytimes.com/2014/08/28/upshot/medicare-not-such-a-budget-buster-anymore.html?_r=0

          • James O’Brien, M.D.

            I didn’t say NHS was responsible for the decline in lifespans, I implied that poverty was.

            If you broaden the welfare state and bankrupt your country, your health status will go down.

            So the US got rich because of crony capitalism? I guess it had nothing to do with liberty and economic freedom? Steve Jobs just knew all the right people in 1975?

            Ironically, our next to no growth rate right now under the smartest President evah is rife with crony capitalism, including the EHR vendors who are making a fortune off a terrible product.

          • Lisa

            I do oppose laws and government that favor corporations over individuals. And that opinion has little to do with where I live.

            Most of the truly wealthy in this country don’t exactly cheat; they use money to shape the law to promote themselves and their business interests over the rest of the population. And I do think we were better off as a country before the Reagan era tax cuts. That was a turning point for the worse in this country history. Wealth does not trickle down.

            I don’t think there is a perfect economic system, a perfect health care system, a perfect anything. But I get awful tired of the those who oppose some form of universal health care in this country spreading disinformation about how awful other health care systems are. And I still say that was the point of the article and you seem to be unable to respond to that point. Enough then…

          • James O’Brien, M.D.

            The point of the article was that she thought something was wonderful because she got decent service and it was free. My point is that attitude is the source of most of our problems.

            Perfect isn’t an option. Neither is utopia.

          • SarahJ89

            Um, that wasn’t the point of the article at all.

          • SarahJ89

            Gosh, Lisa, are you the cuprit who lives in Santa Cruz? How naughty of you.

          • Lisa

            Yep, I live in Santa Cruz. I even count a few economics professors among my friends.

          • James O’Brien, M.D.

            Yep. LeBron James, Oprah Winfrey, Barack Obama all got incredibly wealthy due to slavery and exploitation of resources.

            The typical millionaire is actually a white male in his sixties who worked his butt off and rarely saw his family as a result. But inherited wealth is a cancer that sooner or later eats a society from the inside out.

            Frankly, the estate tax is way off topic and I don’t know why you brought it up except as another excuse to throw insults.

            The first sentence is true. As far as inherited wealth, one of the incentives to wealth is to make a better life for your children. Where is the compassion? BTW most legacy money ends up being dissipated after about three generations.

          • SarahJ89

            I’m married to a CPA. You should really educate yourself about the ins and outs of the estate tax. The typical millionaire is actually a white male in his sixties who worked his butt off and rarely saw his family as a result. But inherited wealth is a cancer that sooner or later eats a society from the inside out.

            What on earth is up with Santa Cruz??? You keep mentioning it. And why do you assume anyone’s in favour of big government?

          • SarahJ89

            We got rich because we stole resource-rich property and then used slave labor to exploit it. Nothing quite like thievery to give you a head start on things.

          • James O’Brien, M.D.

            Nice answer and that would get you an A at UC Santa Cruz. And this explains why we haven’t gotten any wealthier since slavery ended and the Indians were defeated.

            Hong Kong and Japan have no natural resources, while Mozambique does, which is why the former are so dirt poor…oh wait…

          • Lisa

            Japan is suffering economically at this point and having a hard time competing with countries that have cheaper labor. But both Hong Kong and Japan become relatively rich countries because of laws favoring business and business development, as in this country. Same reason China is booming (all of this is relative). The only problem is that anyone who has an option would like to get out of China due to industrial pollution. What do you think is propping up our real estate markets?

          • ninguem

            The Chinese have been propping up our real estate markets not as much because of pollution as their government.

            Mao killed more people than Hitler. The Chinese elites are rightfully concerned their government will go back to those bad old days.

            They wanted a ticket out, just in case.

          • SarahJ89

            Read Guns, Germs and Steel. Or Confessions of an Economic Hitman.

          • SarahJ89

            Starting a foot race fifty yards down the course gives you a pretty permanent edge.

          • Lisa

            Some would argue we still do that – natural resources and use slave (well, nearly slave labor).

    • gleannfia

      Medicare is far more efficient than our multilayered, redundant private insurance-based system. Unfortunately, some want it changed to a voucher program, which would be catastrophic for most elderly.

  • ninguem

    So…..let me get this straight.

    An American Yuppie in central London gets a straightforward corneal abrasion….that I deal with in a private general practice at a cost far less than a thousand dollars….goes to one of the best hospitals in London, gets a straightforward service done, and from this one is supposed to get some great insight into the NHS?

    i suppose, the same insight a foreign tourist would get with a corneal abrasion in an American city, going to a private Urgent Care, getting that same corneal abrasion addressed for far less than a thousand dollars. Assuming one stayed out of hospital-owned facilities.

    I am not surprised at all, that a Central London resident, or tourist in this case, got great care. The British call it “postal code lottery”, and I’d be more impressed to hear how the resident of a council estate in the decaying industrial North, or in rural England, gets treated for that corneal abrasion.

    My rural practice, in a community that gets lots of foreign tourists, I treat that corneal abrasion and send the person back to their hotel and bill their credit card, with a receipt that they can present to their homeland’s healthcare scheme for reimbursement.

  • Allie Goldberg

    I visited there over the summer, and polled a fair number of locals on the matter, and none of them were totally dissatisfied with NHS. In fact, a good number even mentioned how they didn’t mind paying a little bit for it each month, because it ensures that everyone has coverage, including them if they should lose their job. It’s also not an unreasonable amount of money out of their paychecks. My friend showed me her paystub — the percentage taken out of her income was still less than I ever had taken out of mine, and her contribution to the NHS was only about 45 pounds a month. The cheapest ACA plans don’t even come close to that…

    Sure, Dr. Gunter may have had an extra fortuitous experience in one of the nicer hospitals, but I think its important for everyone to recognize that the NHS is not even remotely dreadful like our politicians lead us to believe it is. But only in America will we install red light and speed cameras, but insist that providing national health care is unconstitutional.

  • SarahJ89

    And I can also tell you about my sister whose appendix burst because we lived in the US with no health insurance. She nearly died.

    • James O’Brien, M.D.

      And every ER in America would have treated her free of charge.

      • Lisa

        Every ER in the us might have treated her, but it would not have been free of charge.

        • SarahJ89

          Yes, that’s what happened. However, the fact we had no insurance and could not go to a doctor is the reason she nearly died first. You should not have to wait until it’s an emergency for treatment.

          And I trust you are aware that once treated the patient is presented with a large bill. Yes, you can apply for financial help, although I assure you that information is not forthcoming in my area. The hospital does whatever it can to discourage that.

          Also, ERs are only obligated to stablize a patient. Got cancer that’s treatable but no insurance? Too bad for you. The ER will be of no help until the end when you have to go there to get your terminal crisis stabilized.

          • James O’Brien, M.D.

            And those patients can be treated at county where an aid worker will help them apply for Medicaid.

            Who are these people who have cancer in the US and don’t get treatment in public facilities as a safety net? I want one name. Just one. And if they didn’t that’s on them because it’s available.

            I’m just curious, how much was your sister making when she was uninsured? Because half of the formerly uninsured in America could have afforded but chose not to buy it.

          • SarahJ89

            Rural state. No county hospitals.

            My state until the past few years denied Medicaid to intact families. This meant if your child became seriously ill you either had to separate, go bankrupt or go without. I was a social worker so I saw this over and over.

            What people in one part of our state did was go to the large city in the next state, which subsidized care of our children to the tune of millions. The people who were poor and lived in the mountains faced insurmountable obstacles in implementing that strategy, especially in winter.

            Your compassion is underwhelming.

          • James O’Brien, M.D.

            I noticed you didn’t answer my question about her salary. I don’t automatically buy into every sob story on the Internet. Some stories about the uninsured are sympathetic, some are just people who would rather buy a BMW 3 series.

          • SarahJ89

            Gak. You’re really insulting. And very sensitive all at once. “Flame posting,” indeed.

            My sister was 13 so she had no salary. Our mother was employed full time but had no benefits. Are you satisfied?

            And thanks for the insult. This wasn’t a sob story, it was the truth.

            As for controlling costs, we could stop supporting a bloated military whose main purpose is serving as a funnel for putting money into the pockets of defense contractors.

            As for rationing, we’re already doing that and have been doing that for a long time. I worked when kidney dialysis was rationed. I’ve lived in a country where there was rationing. It exists, as you well know.

            Please stop promulgating the “free ER care” myth. It’s only free until they bill you and the care is only stabilization, as you well know. And like any other bill, some people will skip out on it.

            I’m done.

          • James O’Brien, M.D.

            I didn’t realize asking a rational follow up question to someone I don’t know was an insult. For it to be an actual insult I would have to know you and the truth is your story is unvetted. Since you are using an alias, there is no way to verify anything you are saying. You may not like it but that it the truth.

            Ok, so you support rationing. Fine. Then live with the consequences. If your sister is unfortunate enough to be one of those affected in the future by rationing, then she can blame you.

          • SarahJ89

            Since when is acknowledging something’s existence agreement with it???

            And yes, basically accusing me of making up an “unvetted” story is an insult. And accusing someone of “flame posting” when they have not done it is an insult.

            And dialysis was indeed originally rationed. A cursory knowledge of medical history would make that clear. That is precisely why they expanded Medicare to cover it.

            Since you’ve made it clear that anything I say with which you disagree is “unvetted” or a “flame posting,” there is no point in continuing this discussion, although I’m quite sure you’ll make a point to get in the last word.

            Knock yourself out.

          • James O’Brien, M.D.

            I said IS not WAS. So the answer is you can’t come up with an example.

            Half of the uninsured could afford insurance but chose not to buy it. So its even odds you mom fit into that category. Completely rational followup.

            There was no reason to take it personally. You’re the one with the alias not me.

          • Lisa

            Many states also denied (and still deny) medicaid to childless adults. That is just wrong, imo.

          • SarahJ89

            I believe mine is still one of them.

          • JR DNR

            It’s scary how little compassion is shown here among those who chose caring for others as their life’s work.

  • Karen Ronk

    I think the most important thing to keep in mind when discussing the NHS is the rise of more private doctors/clinics and people willing to pay directly for health care. If the system was as consistently good as this one very isolated incident would purport to claim, then surely people would not be willing to pay out of pocket for care.

    There are good and bad outcomes and care in all health care systems, regardless of how that care is payed for. I believe the actual quality of care should be the only measurement that we focus on and that lack of consistent quality is where the real problems lie. All healthcare costs would decline if the right care was given in the first place.

    • James O’Brien, M.D.
    • SarahJ89

      I lived in two countries with national health or semi-socialized medicine. I have family in one of them. Their health system was excellent when I lived there but has gone downhill markedly since private insurance moved in. The middle class bought insurance so they could get treated in private clinics complete with mini-Disneyland lobbies and let their health system go to pot. Now their economy is bust and many can’t afford insurance but they abandoned their formerly working system.

      • James O’Brien, M.D.

        So it’s the fault of the clinics that were better and that people wanted to pay for (while still paying taxes for something they won’t use) that the public clinics failed?

        In related news, the only reason public school systems perform so badly is that private schools keep showing them up.

        BTW, the scenario you pointed out will happen in the US as people who can afford it opt out of ACA and go to private clinics.

        See how egalitarian policies produce that unintended effect?

  • gleannfia

    unfortunately, these scenarios happen frequently in the US as well. User effectiveness and medical errors are universal conditions. I still vote for a system in which one is not punished with bankruptcy for the audacity of falling ill.
    With regard to people seeking private care in UK, that happens in every system. Those with resources are always willing to pay for more, as with concierge medicine.
    I agree with Lisa that the OPs point is being misconstrued.

  • RES

    And my US physician wife, with abdominal pain, checked out- Gi bug. Pain gets worse, spend Thanksgiving in the hospital (in-Network) with an emergency appendectomy, surgeon on call – out of network. The insurance is the one the hospital provides its employees. (My wife is an attending, but not an employee.)
    So much for quality differences on be basis of anecdotes, so much for US iinsurance giving predictable bills.

  • SarahJ89

    Yes, she did, thank you. But no insurance was the reason she wasn’t taken to the doctor. She wouldn’t have had a ruptured appendix had she been treated much earlier.