The Healthcare of the Nation

Over the past months, two people close to me have been admitted into hospital as emergency cases. One was in England, the other in America. I, too have known the emergency hospital experience in both England and America. I readily admit that these cases comprise a miniscule sample, not a useful guide to the state of healthcare in both countries.

However, let me say that I and those close to me have never experienced unkindness or anything unprofessional from the medics. Mind you, the healthcare experience as an emergency patient is not pleasant. It is scary to find so many professionals gathered around a bed and speaking English in a way that is not penetrable. What the hell is “stat”? There is little dignity either. But what the professionals on both sides of the Atlantic are doing is in the patient’s best interests. They are confirming a diagnosis and applying professional expertise to make an awful situation less bad. Then, over days, weeks and sometimes months, more expertise is applied to provide a cure or a modus vivandi. After all, doctors and nurses are not miracle workers.

The recent past has confirmed my opinion of healthcare workers, both in UK and America. Doctors are well trained, most will listen but they are given so many patients which often prevents the bedside manner emerging. Nurses are habitually kind, caring and professional and will take time to talk to the patients, if time allows. And the porters are usually cheerful and chatty, although they are the forgotten men and women of the hospital. We should remember that without them, things would come to a grinding halt.  

So why does healthcare come in for so much criticism, both here and in USA. Reasons include media, money and politics. First the media. You never see a headline: “Hospital has 98.5% Patient Satisfaction.” Good news doesn’t sell. But a story about the removal of the wrong kidney will run for days. Of course, it should never have happened but it’s a ten million to one chance. An inexperienced clerk, an overworked and tired surgeon, and hey presto. I do not dismiss that a life will probably be lost as a result but where is the media balance? Little or no good news is published.

One story that has not yet been publicised in UK is that NHS nurses are considering industrial action. The nurses have never gone on strike since the NHS was created in 1948 but a miserly 1% pay rise this year, when inflation stands at 2% plus, is effectively a pay cut. This is an example of the UK government’s intransigence on funding when nurses are the lifeblood of the NHS. The media won’t report the story unless the nurses strike.

Where the countries divide most is on healthcare funding. In UK, we have a mutual insurance system. Most beneficiaries of the NHS contribute to its funding through taxation. (Children are excluded from responsibility as most do not pay taxes.) Treatment is free at the point of delivery. No one is asked for a credit card or insurance details when seeking medical help at a hospital or General Practitioner’s practice. However, the NHS has some big problems. First, it seems unable to manage on a £115 billion budget. The NHS has more than a million employees but there are often severe staff shortages, especially at night, which results in huge expenditure for locums. Second, there is a postcode (zip code) lottery where treatment is better in one place than another. These days, the NHS employs numerous managers, who seem to struggle year on year. Perhaps it is not surprising because there are hidden government cuts in funding, year on year. Yet it is the doctors who get criticised.

The USA operates mostly under a private healthcare system. There are federally funded hospitals for those without insurance but my experience is that these are under-funded, where pressurised doctors and nurses are desperate to help with limited resources. And the patients are left with debts they cannot repay. The private system is governed by Health Maintenance Organizations, whose reputation for trying to avoid claims is notorious. The HMO system with its deductibles and coverage differentials is so complex that it needs someone more expert than me to explain it. Insurance premiums escalate annually, often with the excuse that negligence action pay-outs have risen sharply.

Essentially, the “money” difference between the countries could be explained as the UK being service driven and the USA profit driven. But this is simplistic and naïve. The Thatcher government introduced market competition into the NHS but it has never worked well. And I am certain that HMOs don’t always seek to cheat their customers at the outset; it’s more likely that the latter haven’t read the small print carefully.

Where I have major issues is politics. In the UK, the NHS has been a political football. Successive governments since the 1970s have tried to introduce different management and costing systems to make the NHS efficient. The government does not want to accept the service is demand-based. You cannot budget successfully if you don’t accommodate for the vast numbers of people who seek to use the service, increasing every year. I do not have a perfect solution but other countries, like France, have managed well. Why do we not introduce new rules to require a contribution, in addition to that paid via taxation, for use of the health service, which in turn can be covered by insurance? Would most taxpayers really object to a £5 levy for seeing a GP or £25 per day for a hospital stay? However, the NHS is the “third rail” of British politics. It is an entitlement so if a politician touches it, his career will die.

There are other interesting suggestions to improve the NHS. For example, place a team of GPs at the front door of every A and E (ER) Department to help some 30% of patients who do not actually need emergency hospital care. And the government should be honest with the public about the real choices if, as a nation, we do not spend more on the NHS as a proportion of our gross domestic product. However, healthcare is the most complex and difficult of topics that government faces and I don’t pretend solutions are readily available and easy.

As for USA, I am no expert on Obamacare but a government policy that enabled 20 million more Americans to benefit from health insurance was significant. Republican political ideology to damage and defeat Obamacare is anathema, if those 20 million and probably many others will cease to have insurance and, more important, peace of mind. The Trump administration and Congressional Republicans are all over the place on how to replace the Affordable Healthcare Act. They said it was an easy fix. Really?

What I dread for Americans is an Unaffordable Healthcare Act, accompanied by a return to Republican political ideology of the 1920s: ‘wealth is a sign from God that he approves of you and poverty is a sin.’ Is such a return unthinkable? Well, so is a nuclear war with North Korea!