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Rapid Responses: Rapid Responses published:
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A different perspective
- Karen Lee (22 December 2000)
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Nationalised health care differs from free health care
- Wen-Hann Tan (27 December 2000)
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Re: A different perspective
- Harley Gordon (27 December 2000)
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Why compare UK and USA?
- Pawan Randev (29 December 2000)
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Comments on historical context.
- Martin Moran (3 January 2001)
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The NHS through American eyes
- Peter H Millard (18 January 2001)
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Karen Lee, Training Coordinator Trafford SMS
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I too am an American with an 'inside' view to the NHS. Unfortunately part of my view is built upon my experience as a patient while the other part is formed from my employment by a NHS Healthcare Trust over the last three years. First, from the perspective of a patient, apologies but the standard of care in NHS is appalling. I have a congenital kidney disorder that reared its ugly head last year for the first time in 12 years. This is not the place to provide explicit detail I will only say I have never experienced a lower quality of care, with inefficiency the rule, and unprofessional practice the norm. In addition the conditions of the hospital were filthy, rundown, ill equipped, and 'unclinical'. I am afraid to have to depend on the NHS should I incur further problems. So I am a member of a private scheme because one must be in order to ensure medical provision is available. Yes the mission of the NHS is admirable but it is not functional. It proposes to be free healthcare for all. But it is not free. The bulk of moneys being drawn from NIS contributions. This means that my husband and I pay just under £400 a month for healthcare, this includes £50 a month for the private scheme. Contrast this to the US where as a public sector employee I never paid more than $50 a month for a MUCH higher standard of care, in which the latest technology was available to my doctors who were specialists. I am sure that I could purchase health insurance in the US for the equivalent of £400 a month that would be of this higher level of care in much better facilities. As an employee of the NHS there is the constant problem of underfunding, short staffing, lack of support, shortages of equipment, etc. I have beeen stunned by the task before me as I go out to train in primary care as well as in the hospitals. The great majority of GP's I have met are not people I would trust with my health. I do think the mission of the NHS is admirable but it is not achieved, perhaps unachievable. I do not think the NHS is a model the US should be looking to. I say that as a patient and as an employee. |
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Wen-Hann Tan, Senior House Officer Addenbrooke's Hospital, Cambridge
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Leatherman and Berwick espouses the ideals of the NHS, and indeed the philosophy behind the NHS is admirable. However, the main problem with the NHS is that it creates a market in which the demand exceeds the fixed supply, but unlike other economic markets, there is no mechanism through which the demand can be regulated. Because it provides services free at the point of delivery, users of the NHS treat it as a "free good" notwithstanding what we pay for it through our taxes, and this is unsustainable in the long term. Economically, the NHS is a scarce resource, and we should introduce a "price" into it in a way such that the demands on it can be fairly distributed. Charging a fixed price for A&E attendances regardless of the severity of the medical condition for example, would be a simple way of controlling its usage, because patients with trivial illnesses would be less inclined to attend A&E departments if they had to pay for it -- the inherent price elasticity of health care demands. Yes, we should depoliticise the NHS, but it is time our politicians take a good hard look at the NHS to see how we can square the supply with the demand to ensure that the NHS remains the "envy of the world" as one health secretary liked to call it. Otherwise, we in the NHS will one day become exhausted hamsters unable to run any further. |
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Harley Gordon, Clinical Associate Professor of Pediatrics Health Sciences Centre at Brooklyn.
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Karen Lee has been unfortunate in her experience of the NHS, I wish her well, and hope the experience is exceptional. Here too in the US medical care ranges from good to bad.Health statistics are no better than in the UK, or less good. She claims that for 350 pounds a month- their NIS payments- she and her husband could purchase higher level care than is available in the UK. Maybe. Insurance premiums in the US are not geared to income, consequently over 15% of the population whose income is low cannot afford, and has no, medical insurance. Further she might be refused, or offered a risk related premium. The insurance would be unlikely to be comprehensive, and carry deductibles and co-pays, or even exclusion for her pre-existing disease. And an employer might hesitate to employ her because a group policy is experience rated, if her condition might result in large expenses. In concept and structure, the NHS has nothing to learn from us, it may well need to improve funding and standards. Its universality and comprehesiveness, commitment to primary care, are what we need to study. Finally she never received insurance for $50 a month, her employer paid the balance, as a benefit. |
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Pawan Randev, GP Measham
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In this editorial the comparison is made between two flawed systems. The WHO study that places the UK at number 18 also has the top 5 systems. My (probably flawed) recollection was that France came top of the poll. It would be helpful to make comparisons with the system that delivers the best outcomes. |
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Martin Moran, Family Practitioner Maine Medical Center. Portland, Maine, USA
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This article presents the NHS as if in a crisis for which an appropriate remedy will produce recovery. The status quo for healthcare in Britain may infact be a crisis such as currently exists. 100 years age The Times produced an article on the severe problems in delivering healthcare affecting both the charitable and non-charitable hospitals in London(1)and continuing concerns led to the establishment of the NHS in 1948. The breadth of material covered in this article when condensed for publication lends itself to a polemical style which Berwick and Leatherman may not have intended. In contrast Berwick and Smith eloquently stated the case for improving the NHS in 1995through the creation of learning organisations based on collective knowledge(2). We may have the usual crisis in health care but we also have a means to address it. (1) 100 years ago. The finances of the London Hopsitals. BMJ 1995;310:456 (2) Cooperating, not competing, to improve health care. Berwick D & Smith R, BMJ;310:1349-1350. |
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Peter H Millard
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Editor - Everyone sees the world from the point of view on which they stand. Seeing the National Health Service through American eyes, Leatherman and Blackman believe that the NHS has fundamentally "got it right" (23-30 December pp 1545-6). Yet, fundamentally, the NHS no longer exists, for the 1990 Community Care Act changed the 1948 legislation that underpinned it. The National Health Service, Operational Research and Rehabilitation were three health care legacies of the Second World War 1. The operational plan that underpinned the NHS, transferred wards full of bed bound patients to hospital care, from local government care. From that unlikely beginning, the specialty of geriatrics began. 2 Take hospital responsibility for providing a free long stay service away and the driving, rehabilitative force, that underpinned the NHS ceases to exist. During the Thatcher years a cruel trick was played on pensioners, as well as on entrepreneurs. Using the rhetoric of markets, choice, and quality, responsibility for long stay care for sick and disabled people was transferred, by slight of hand, from the hospitals to the private and voluntary sector. Thousands of hospital beds were closed; consultants in geriatric medicine took on general medical duties; general physicians became specialist physicians; waiting lists disappeared; everyone was happy. Accept, that is pensioners paying for their own care. In April 1993, government closed the open door. Now, we have the worst of all deals. The NHS no longer exists; pensioners are being told that they should insure for their long term care; nursing is being redefined to exclude personal care (such as washing, dressing, feeding, toileting); waiting lists are growing; acute hospital beds are full; and the whole pack of cards is collapsing. To make matters worse, the generation who fought the Second World War is now in need of care. Yet New Labour is moving inexorably, away from Beveridge, towards a Bismarck model of care for older people;3 soon, no doubt, everyone will be means tested for long term care. What is needed now, if a long-term vision for health and social care in the United Kingdom is to be achieved, is a coherent, equitable, just and efficient plan for all citizens acute, rehabilitative and long stay care. Prof Peter H. Millard, MD, PhD, FRCP. 1. Timm, O.K. (1967). Rehabilitation to what? Journal of the American Geriatrics Society, 15, 709-716. 2. Department of Health (1981). Report on a study of the respective roles of the general acute and geriatric sectors in the care of the elderly hospital patient. Department of Health. London. ISBN 0-902650-34- 3: |
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