What really struck me about the contrast between Britain’s National Health Service and what we have here in the United States was not how I was treated over most of a week last summer at an NHS hospital in Oxford, though my care was excellent. It was what happened after I was discharged.
It was a Sunday evening, and my wife, Joyce, and I had just returned to our hostel after my five days of treatment at a nearby hospital for suspected congestive heart failure. I realized I’d neglected to pick up the diuretic pills the doctor had prescribed for the plane ride home to prevent my lungs from filling with fluid as they apparently had during our flight from Philadelphia 10 days earlier. I was distraught. The pharmacies were closed, and I had no prescription, since medicines prescribed at the hospital are also dispensed there (for free) as patients are discharged. I called the hospital and spoke to Dr. Mridula Rajwani, who had overseen my care. I explained what had happened, apologizing profusely.
“Oh no,” she replied. “It’s our fault for letting you leave without your medicine. But no matter. I’ll have it messengered over to you straight away.”
I was stunned. Sure enough, 50 minutes later, a messenger arrived with the medication. I asked what I owed him. “Nothing sir,” he said, “I’m just doing my rounds.” He explained that many patients need medicines delivered after they’ve been released, and that the hospital delivers them to those who cannot pick them up.
Imagine this happening in the U.S., where hospitals itemize each pill on a patient’s bill, and where an aspirin or Tylenol can run $15 or more (plus an additional charge for “administering” it).
My insider’s look at Britain’s National Health Service began shortly after we had flown to the U.K. to watch our daughter receive her doctor of philosophy degree at Oxford University. We landed first in Edinburgh, where my harpsichordist wife had an appointment to play some of the 18th-century harpsichords on exhibit at the St. Cecilia’s Hall music museum. As we walked from the train station to our hotel with our wheeled carry-on bags, I found myself getting short of breath on ramps and gentle inclines. A life-long runner and regular gym-goer, I had never experienced this before and chalked it up to exhaustion from the red-eye flight. But over the next five days, as we went on first to London and then to Oxford, my short-windedness worsened until I couldn’t make it up one flight of stairs in our hostel without gasping for breath.
My daughter arranged an appointment with a private physician who discovered fluid in both my lungs and a blood oxygen saturation level of just 90, a level you’d expect for someone with pneumonia. He said I couldn’t safely fly home as planned. Instead, he sent me to John Radcliffe Hospital’s ambulatory assessment unit (AAU).
Oxford’s main NHS hospital is a typically huge teaching facility, but arriving there the next morning, I was struck by the friendliness of the staff and by the clean, well-lit hallways. Surprisingly, we were directed to the fifth-floor AAU with no stop for registration, admission or proof insurance or ability to pay. The AAU had a large, comfortable waiting room equipped with a free coffee/tea dispenser and baskets of fruits and crackers, along with current reading material and a TV. We chatted awhile with other waiting patients until a nurse came to sign me in. She already knew why I was there, as the physician who had arranged for my admission had reported my symptoms. A staff doctor soon arrived, a GP who took me to an examining room where he questioned me about my symptoms and medical history while a nurse took my vitals.
Later that day, I was seen by a cardiology specialist who explained that they would start me on a course of IV-administered diuretics to help dry out my lungs and schedule an X-ray, CT scan and echocardiogram to look at my lungs and heart. The doctor suspected congestive heart failure. It was shocking news to me but delivered calmly, with the assurance that they’d take care of it.
The idea behind the AAU is that some patients just come into the hospital by day for tests or treatment and then return home each night. This arrangement is often more comfortable for the patient and also frees up beds and hospital staff for patients who have to stay in bed and have nursing care available.
I thought of the times I have been hospitalized over the years for various injuries — broken arm, broken leg, torn-up knee — and how each time I’d lain in bed for days, bored to tears, while I could have been home or even limping around in school. Why don’t we have such units in every hospital back home, I wondered.
At any rate, I watched as other patients, like me, were seen with similar caring efficiency by the unit’s busy doctors and nurses. At lunch each day, a woman came in pushing a big cart full of hot food. She would describe the options — fish, roast chicken, beef — and then add, “If you don’t like what we have here, just tell me what you want and I’ll go down and get it for you from the cafeteria.” The meals — quite appetizing — were free not just to patients but to family members and caregivers who were with them.
Again, I thought of my experiences in U.S. hospitals, both as patient and as father, son or spouse of a patient, and of the sorry vending-machine fare available in most hospital waiting rooms. “Why can’t we do this?” I wondered.
My X-ray and CT scan were completed the next day, and the echocardiogram several days later. All involved minimal waiting. The physician team’s conclusion was as predicted — suspected congestive heart failure — though both the cardiologist and a pulmonologist also suspected that an inflammatory condition I already had in my lungs, sarcoidosis, probably was playing a role.
On the second day of my visit to the AAU, a man from hospital administration came up to me and politely asked to see my passport. Then he asked if I had insurance. I told him we had Blue Cross, and he said, “Oh well, we will bill them for your stay, but they never answer us. It’s because we don’t have any codes for services. We just account for patient stays by the number of days you’re here and they don’t know how to deal with that.” He explained that the NHS doesn’t charge British citizens and others who are covered by the system, like foreign students. He said that even if I did receive a bill eventually, “It won’t be very much money.” He added, “A lot of people who come here from other countries just don’t pay and if you do that, it won’t matter.” He laughed, adding, “You won’t be arrested at immigration for nonpayment if you return to the U.K. a year later for a visit.”
I said if Blue Cross didn’t cover my bill simply because there were no codes for the services I’d received, I would “raise hell” and demand that they pay, especially since I suspected my total bill would be less than the cost of the CT scan back home. (I was right. Three months later, I got a bill for $990 — not bad at all for all the tests and for five days in the hospital, not to mention being seen by five doctors and two specialists several times.) I submitted the bill along with my detailed discharge record showing all the tests and exams I’d had, but it took over six months of haggling before Blue Cross’s international unit finally approved a reimbursement of $690 of my $990 bill. They said they were deducting $100 per day for the first three days of my hospital stay. No amount of explaining by me that the bill was not just for the hospital stay, but for all the tests and physician care I’d received, would change their minds. Blue Cross did pay my private physician bill for two office visits and a phone consult with the private doctor my daughter had arranged to see me – a total of over $800. That office used a code Blue Cross apparently recognized – and charged an amount Blue Cross was used to! – so it posed no problem.)
When my case was being investigated, Dr. Rajwani, director of the AAU, informed me that I could certainly opt to stay in Oxford for further tests, such as an MRI, to investigate the cause of my apparent heart problem, and to receive treatment too, but she warned that the cost of hotels for my wife and myself might be prohibitive. Alternatively, she suggested, they could finish drying out my lungs and getting my blood oxygen level back up to a safe and healthy 98 percent. Then, armed with diuretic pills, she said I could safely fly home and, as I had good insurance coverage, see a cardiologist in Philadelphia for further examination and treatment.
We opted for the latter approach.
My flight home was uneventful (except for my poor seatmates, who had to endure my frequent trips to the loo), and two days later I saw my new cardiologist at the University of Pennsylvania, Dr. Ronald Carabelli. Reviewing my records from the NHS, and the DVD images they had provided, he commented that I had received excellent care and a diagnosis of congestive heart failure that he unfortunately agreed with. But he said he wanted to do a second echocardiogram as well as an MRI and a full heart catheterization to check the valves, coronary arteries and pulmonary blood pressure. “I want to try and figure out why you have this heart condition,” he explained, saying that given my general physical condition it didn’t make sense to him.
With my Blue Cross plan, cost was no object, and happily, after he got the results of all those tests, he told me, “Dave, looking at these results, which are all good except for a slight elevation of your pulmonary blood pressure, I have to say I don’t find anything wrong with your heart. It’s your lungs. You need to see your pulmonologist to deal with that.”
And so that’s where things stand now: No congestive heart failure, but an autoimmune sarcoidosis condition that needs to be monitored and treated with steroids as necessary.
Looking back, I’m in awe at the care I received in the U.K. There was no “wallet biopsy” when I first arrived at the hospital, as is the standard in the U.S. The total cost of my treatment was less than what a U.S. hospital would charge for an ER visit, a CT scan or just one night’s stay for observation. And that’s not to mention all the charges there would have been in the U.S. for doctors seen, other tests done, medicine administered and a laundry list of other charges for equipment and other medical materials.
Those three outpatient tests Dr. Carabelli ordered cost a staggering $51,890. Even the negotiated fee Blue Cross paid the University of Pennsylvania Hospital for them came to $12,470. The NHS charge would have been nothing. (And I paid nothing for the tests here under our health plan, but that $12,470 contributes to the soaring premiums we pay for our insurance coverage.)
I’ve been assured that I would have been treated exactly the same at Oxford whether I had money and insurance or not. That was made clear to me by the administrator who took down my passport and Blue Cross information and by the doctors and nurses I met, who were all NHS employees. The same cannot be said for the U.S. Dr. Steffie Woolhandler, professor of public health at the City University of New York and co-founder of the organization Physicians for a National Health Program (PNHP), says that even public hospitals, presented with an uninsured person complaining of sudden shortness of breath, , might turn that person away, or simply give them diuretic pills or antibiotics, since shortness of breath and even some fluid in the lungs might not be considered a “life-threatening” condition. (The “dumping” of patients without insurance by hospitals in the U.S. is on the rise. CBS reports that the Illinois Dept. of Public Health, for instance, investigated 1,000 such cases in 2016 alone.)
Britain’s NHS has suffered decades of budget cutbacks and hiring freezes under both Conservative and “New Labour” governments and is these days woefully short-staffed (particularly evident during last winter’s flu season). Even so, everyone with an urgent medical condition gets treated. There are no “uninsured” patients in the U.K. Yet the per capita cost of providing all this medical care in the U.K. works out to just over $4,000. That compares to over $10,000 per capita in the U.S., with our jerry-built amalgam of Medicare, charity care, Medicaid, Affordable Care Act, Veterans Affairs and private, employer-based health insurance. We pay premiums for private insurance and taxes for Medicare and Medicaid, all of which still deny us coverage for needed care. Not only that, but tens of millions of us have no insurance at all and cannot afford to get it, or even to see a doctor. Meanwhile the U.K., for 40 percent of what we as a society spend per person on health care, has a unified system in which hospitals are state-owned and physicians and medical staff are state employees, and everyone gets covered.
The U.K. currently ranks 18th in the World Health Organization’s ranking of health care systems among 190 nations, behind countries like France (1st), Italy (2nd), Singapore (6th) and Norway (11th), and ahead of Switzerland(20th), Sweden (23rd), Germany (25th), and Canada (30th). The U.S. ranks 37th.
Oh, I know, there are the notorious waiting times for non-emergency “elective” surgeries, like replacement knees or hip joints in the U.K. But the truth is, if you try, as friends of mine have, to schedule a knee replacement with the surgeon of your choice, or with a surgeon your insurance will cover, it can take half a year or more to get the appointment here, too. And the difference is, in the U.K., you will eventually get that knee replacement, while in the U.S., without insurance, you probably never will. Besides, most of the problems with the NHS are not because it is a “socialist,” government-run system. They’re the direct result of budget cutting by Conservative or Neo-Liberal governments.
Several recent U.K. governments have recently have been making things worse by introducing competition with private doctors and hospitals, and even elements of privatization within the NHS, such as encouraging public hospitals to rent out floors for private-physician patients, which, of course, means fewer beds for NHS patients. The main result so far of these “reforms” has been that medical fraud, once an insignificant issue, is starting to resemble the U.S., where the FBI estimates it accounts for at least 10 percent and possibly as much as 20 percent of the nation’s annual $3.4 trillion medical tab and where administrative costs — mostly vain attempts to prevent or detect that fraud — account for nearly a third of the nation’s $3.4 trillion annual medical outlay.
But here’s the thing: As a long-time advocate of nationalized health care — whether the U.K.’s NHS model where hospitals are state-owned and medical staff are all state employees, or the single-payer approach in Canada where the government as the sole insurer negotiates the reimbursement rates for private hospitals and doctors — even I was dismayed when I learned I’d have to go into an NHS hospital. Years of biased reports (often based on industry-funded studies) in the U.S. media about long waiting lines and cursory visits to see disinterested and overworked NHS physicians had prepared me to expect the worst. Instead I found dedicated nursing staff and doctors, and efficient and caring treatment by people who always took the time to answer all my questions. And no wasted time working my way past an admissions gatekeeper looking to make sure the hospital would get paid.
Allyson Pollock, a prominent advocate for the NHS who decries all the budget cuts it has suffered and who blasts the current “reforms” aimed at “marketizing” its operation, told me that even if Oxford’s John Radcliffe Hospital is perhaps newer and less stressed by an overload of patients than some NHS hospitals, “you would have received the same level of care at any NHS hospital in the country.” Pollack, director of the Institute of Health and Society at Newcastle University, attributes this to a “culture of care” that has been at the core of the NHS since its founding in 1948 and which she says endures despite the strain of budget cuts.
Instead of Britain trying to adopt aspects of the U.S. health care “system” (if our staggeringly complex, bureaucratic hodgepodge of government, private and not-for-profit institutions and government and private insurance can even be called that!), it seems clear to me that we in the U.S. — with our uniquely costly medical model at a crossroads — should be looking to the U.K. and to Canada as models of systems that deliver equal or better care to all their citizens. Those countries deliver universal care at little or no charge to the individual patient, achieve better national health outcomes and statistics, and they do it at far lower cost than the complex mishmash of a system we have here.
Dave Lindorff is a freelance writer living near Philadelphia. A former correspondent for Business Week in Hong Kong, he is author of Marketplace Medicine: The Rise of the For-Profit Hospital Chains (Bantam 1992) and is a contributing editor to Salon, The London Review of Books, Counterpunch, High Times and other publications.
