A Texas longhorn in Queen Elizabeth’s surgery
By Richard Young, M.D.
We walked down a narrow pedestrian-only street in the small town of Litchfield, England, which is a bedroom community near the second-largest city in Britain, Birmingham. I was following Dr. Helen Stokes-Lampard, an English general practitioner I had begun corresponding with over six years ago. I had read about the British National Health Service for years and had always wanted to see it firsthand. This September I finally got that chance, though I didn’t get to meet the Queen.
We were making an afternoon house call after the morning surgery session. “The surgery” is what British general practitioners call their clinic. (I have no idea why. They call surgeons “surgeons,” so why call a clinic a “surgery”?) A 92-year-old patient of the practice’s patient panel reported severe hip pain and Dr. Stokes-Lampard thought it would be a good idea to walk to her residence to check on her.
We walked past modern retail consumer shops that seemed patterned after some American stores: T. K. Maxx, for example. Of course one notable difference is that these shops were in Tudor-style buildings that were over 300 years old.
We arrived at the equivalent of a low-intensity assisted living center, where we found the woman sitting in a chair with another resident of the center visiting with her. Mrs. Jones said that the pain started the previous evening and was worse than when she had her daughter. But she did not call the ambulance during the night. She waited for her general practitioner to come visit her the next day.
The visit was free to Mrs. Jones. One of the founding principles of the NHS is free care at the point of service. It’s not totally free, however. Patients have to pay for prescriptions and supplies, such as eyeglasses, and some durable medical goods are not covered. But doctor’s visits and hospitalizations are completely free to the patients.
After Dr. Stokes-Lampard talked to Mrs. Jones for a few minutes, the doctor excused herself to wash her hands and I took the opportunity to help Mrs. Jones use her “frame,” or walker, to shuffle to her bed for the examination. It was a slow go and she could not swing her legs from a sitting position on the bed to the surface of the bed by herself because of the pain.
When Dr. Stokes-Lampard placed her hand around Mrs. Jones’ hip, she let out a loud groan, but the same response was elicited when the doctor placed her hand on the abdomen. The doctor was worried about a possible surgical abdominal process and began arrangements to have her patient seen by the local surgeons at the hospital.
Dr. Stokes-Lampard would not see her patient in the hospital. This is the result of an agreement between physician factions struck in the early days of the founding of the NHS in the 1940s. General practitioners only work in the outpatient setting; internists cover the hospitals, but don’t provide primary care. This makes more sense in a country where essentially everyone is within an hour of a major hospital. There is no equivalent in Britain to Fort Stockton.
Dr. Stokes-Lampard made several communications while concluding her care of Mrs. Jones. She called the surgical clinic of the hospital to let them know her patient was coming. Essentially all specialist and surgical offices are located at hospitals and these physicians and surgeons are paid a salary from the general hospital fund. She also called the ambulance service. It might take a few hours for the pick up, but this was felt to be reasonable under the circumstances.
Finally, the doctor dictated a letter to the surgeon consultant. This was a notable difference between my observations of Dr. Stokes-Lampard and even American doctors in private practices I’ve observed. Both sides of the U.K. general practitioner/specialist camps spend a significant amount of time writing letters to each other. I’m sure this is no surprise, but the letters are sprinkled with polite phrases such as “would you be so kind as to …” and “Thank you ever so much.” I was in Britain after all.
When all seemed to be in order, we left Mrs. Jones’ flat and walked back to the surgery.
The surgery itself was in a much newer building that looked much more like what a stand-alone large American clinic building might look like. Some of the notable differences included the fact that each general practitioner worked out of one combination office and examination room. The patient waited in a small outer room and was invited into the consultation room only after the previous patient’s visit was completed.
Dr. Stokes-Lampard scheduled a visit every 15 minutes, which is longer than usual. She did this to allow a little extra time to explain to the patients why a stranger was in the room and for me to ask questions. The standard consultation time is 10 minutes and they usually don’t deviate from this. The general practitioners use electronic medical records, but they are required to document much less than American family physicians, and their system is much easier to use and more helpful than the system I have to use, or any other one I’ve heard of.
The surgery used to post standard-issue NHS signs that read, “A consultation should take no more than 10 minutes.” They removed them because they thought the signs were tacky. However, the culture of the 10-minute visit is understood by both doctors and patients. The visit is free to the patient, but they can only talk about one issue. Being human they often try to squeeze in another concern if the general practitioner lets them get away with it. Practice nurses help with some of the routine chronic care by phone and occasionally with home visits.
Another difference is that all the routine childcare and immunizations were given by nurses in a separate area of the clinic. There are pediatricians in the U.K., but they do not provide routine primary care. They are hospital-based consultants. A common division of labor might be for the general practitioner to care for a child with mild asthma; the pediatrician a severe case.
I tried to visit the NHS with an open mind, but my reaction to the trip was that my biases were confirmed. The secret to the incredible efficiency of the NHS – better health outcomes than the U.S. at half the cost – isn’t whether or not it’s socialized. As I have written in my book, American HealthScare, whether or not a government agency, a private insurance plan, or a patient paying out of pocket spends $1,500 for an MRI, the more important question is what is the effectiveness and cost-effectiveness of the MRI in the first place? Should it even be ordered? The NHS, the doctors I observed, and most importantly the British patients were much more humble about their expectations of what their health care system should provide.
A few days later we found out how Mrs. Jones fared at the hospital. She got a plain x-ray and a few blood “investigations” (British for tests). They were reassuring and she was given a relatively mild pain medicine prescription and after about three hours was sent home. The surgeons’ conclusion was that the arthritis in her hip just flared up. Mrs. Jones was extremely grateful to her personal general practitioner, the hospital, and its doctors for the care she received.
Imagine it. A patient who did not receive a CT scan, MRI, or a definitive diagnosis, but who was extremely happy with a prescription for a mild pain reliever and the fact that people cared for her. I saw it happen in Litchfield, England. Wouldn’t it be nice if it happened here?