Before I started training in dermatology in the 1980s my boss suggested that I went to Vienna (a Mecca for all things dermatological) to see how others practised medicine. They accepted me as a visiting fellow, observing clinical practice and doing research. What still shocks me is how differently medical care can be configured.

I had just completed the mandatory pre-dermatology training of one year of house jobs and three years of internal medicine. Things were very different in Vienna. Not only did my new colleagues think I had wasted several years studying subjects peripheral to my career choice, but they were incredulous to hear that UK patients were unable to access dermatological care directly, having instead to go through the gatekeeper of the general practitioner.

I repeated the standard NHS mantra about how patients needed a primary care doctor to help them navigate the complexities of medicine. My Austrian colleagues initially assumed that our differences resulted from linguistic confusion secondary to my rudimentary German. They spoke slower, in English: “You mean that …