I went to visit my 93year old grandmother today. One of her carers told her the doctor would be visiting later. She gets confused and immediately started worrying that she didn't have enough money to pay the Doctor. We reassured her but it got me thinking about the UK's system of health care.
On July the 5th 1948 the UK government introduced a system of health care that was free to all dependent only on citizenship. Care was unlimited and treatment was on diagnosis rather than financial means. The UK at that point desperately needed change as disease was rife and the poor were dependent on the charity of some doctors or worse still the workhouse. Hospital care was refunded but had to be paid upfront.
The NHS has not been without it's problem's primarily because it is chronically short of cash but 60years later it does mean that any patient regardless of age, financial status, employment etc will receive equal care on the basis of diagnosis.
I realise that worldwide there are many differences. I recently had a fantastic American patient in the UK on holiday - he had chest pains so needed, baseline assessment, chest xray, bloods, ECG and a doctor's consultation all of which as an emergency are free which he couldn't believe. On the flip side I went to India recently and although hospital care is free patients need to pay for medication and the cost of this often is prohibititive meaning that the mortality rate amongst the poor remains unacceptably high.
I would be so interested to hear of how other countries provide health care and what works about these systems and also what doesn't. Maybe we can come up with a worldwide effective system that promotes equality and inclusion :)
Well, up here in the Great White North our taxes pay for universal healthcare. From what I recall the NHS is also paid for via taxes (correct me Sharrie but I believe it's called National Insurance).
What I see wrong with the Canadian system, is the sense of entitlement people have. When our system was set up, it was to ensure that basic healthcare was covered without people having to worry about losing the farm to pay for it. General visits to the Doctors and surgeries, that kind of thing. Now it covers longterm and continuing care, some what would be considered cosmetic surgeries (if deemed medically necessary), penile implants, visits to obtain Viagra.
It just seems that people expect to cover everything not just the things required to ensure general well being. I don't consider penile implants or Viagra as necessary and life threatening. Others object to terminations being covered. I've heard of people having their sweat glands in the armpits removed because they felt their sweating was detrimental in social situations.
When you need care it's there. You might have to wait on a list for some procedures but a wait is better than never being treated because you can't afford the visit to the Doctor to be diagnosed.
The UK system, the NHS was founded in 1948 by Aneurin Bevan. It was founded on the core principles that the health service would be available to all and funded by taxation, that way people would pay into it according to their means. (this is our National Insurance which I believe sits at about 11% of your earnings)
The government sets our targets of what we should be achieving, so things like waiting times for treatment are fixed and hospitals have to achieve them. For non urgent cases the target is from your initial referral to treatment is 18 weeks. So if you have a hernia that needs repairing for and your General Practitioner refers you to the hospital today you ca expect to have your operation by June, for urgent of cancer patients the time for referral to treatment is 31 days.
As far as clinical decisions go, the day to day decisions are made by the clinicians, although there are a few treatments that we do have to ask permission for such as Vac therapy because of the cost, this is assessed by our wound care nurse who if she feels it is beneficial will authorise treatment, the funding is never refused providing this nurse approves it. Emergency targets are also dictated by government so that no patient should wait longer than 4 hours in the emergency unit for treatment.
We have an organisation called the National Institute of Clinical Excellence (NICE) who produce clinical recommendations for treatments, these form a big part of our clinical policies, so they have hypertensive management guidance, management of dyspepsia, and recommendations for cancer treatments (there are lots more) the government will use these to tell us what we are allowed on the NHS, however NICE is run by clinicians who look at the best evidence when drawing up their guidance, this is where you will find the news stories about patients who have been refused cancer treatments, it is usually because NICE does not feel that the treatment has sufficient evidence supporting use, they look at the clinical benefits, numbers treated and cost of the treatment to establish if it is the best use of NHS resources.
OK then that's the facts and figures, now the reality.
I think that we do very well with our emergency care, the acutely unwell are treated very quickly and we are closely monitored on things like door to needle time etc, the pre-hospital care is also monitored in a similar manner. If you present at the emergency unit with a MI you will be in an appropriate unit within the hour receiving treatment.
We have made huge improvements in waiting times and patients are getting operations sooner, I like this and think the targets have improved care, especially for our cancer patients. We have excellent health promotion and disease prevention programs run by our primary care services who are paid extra for achieving things like normalising blood pressures, making sure that diabetics are monitored and are well controlled, we have routine breast screening for over 50's and mens health clinics, smoking cessation, obesity clinics. The primary care doctors will be rewarded financially for these initiatives.
However I do feel that sometimes we can compromise care on the wards to support our emergency patients, when EU is full to bursting we have patients on trolley's put onto wards, the nursing staff are then encouraged to discharge patients quickly to make the extra capacity and I do feel that we sometimes rush our patients to make sure we meet the targets. I know that noone wants to wait in EU for longer than 4 hours but I struggle to justify pushing a patient with an abscess who could be drained on the unit to a ward to make sure that these are met, wonder if sometimes the targets overtake clinical need, not all of the time but sometimes.
The NHS is chronically short of cash, the organisation I work for is millions overspent so we are constantly asked if we can cut resources, not recruit to help reduce this deficit. This means that things like overtime and getting agency nurses to cover sickness or absence is very difficult, meaning that the staff already under pressure are working short handed alot of the time.
I think that there is a great deal of waste in the NHS, things like stock control, medications, we don't book them out to patients, so we aren't accountable for what we use, I wonder if we had to justify why we are opening a packet of 10 gauze swabs rather than a packet of 4 we could reduce waste, but because patients don't pay for treatment we don't monitor what is used for what patients. Things like controlled drugs are closely monitored.
Our health and social care systems work independently, which means that often we have patients in hospital awaiting social care input before discharge. There appears to be a chronic lack of facilities for the patients who are not ready to go home but not acutely unwell so they sit on the acute wards waiting to either get better or for a transitional care bed to become available. Access to social workers takes quite a long time, which again can delay discharges and then there is the discussion about who funds the care in the community is it health or social responsibility, again this takes time and delays discharge.
I've always lived and worked in a country where health care has been paid for by taxation, and I am not sure I would want it any other way, but I do wonder if we paid for health care differently would our expectations be different. Our patients come to hospital knowing that staff are overworked and busy, you wouldn't tolerate this in a shop or restaurant but we accept it in our health care and I don't think we should. I would like to see that our patients are treated as customers rather than patients and with that in mind staff the wards appropriately to make sure that our customers needs are met
There are variances within England, Wales, Scotland and Northern Ireland as to what you get on the NHS, all medical care is provided in all regions but in Wales and I believe Scotland Prescriptions are also provided however in England you have to pay a nominal amount to fill a prescription. We pay for dental care (there are NHS dentists but we still pay for the care provided and it is getting more difficult to find a dentist that provides NHS care for adults. Children are covered with all dental care, we also pay for opticians but those who are claim benefits (unemployed, disabled, elderly and children) get free optical care.
Specializes in Medical and general practice now LTC.
Just to add my tuppence to Sharrie as I worked in the community for several years in the UK
GP's and GP surgeries also have targets and policies to follow and have seen many occasions where medications have been changed to a cheaper or more efficient version, for example I remember a period where we changed all or most of our patients from Simvastatin to Pravastatin as directed by our PCT (primary Care Trust) Times are also set on how long a patient should wait to see a GP or NP and we went from a 2 week booking system to a same day system with some time set aside for bookings for non urgent stuff. We also started telephone consultations with the doctors taking turns and this worked out well for people who wanted to just talk quickly with the doctor and actually saved time in the surgery as a patient wasn't taking a 10 minute appointment for something that took 2 mins. If after consultation over the phone it was felt the patient had to come in and see the doctor then they would make the appointment. We also encouraged patients to see the practice nurses as a lot of things could actually be sorted with them. Practice nurses also did chronic care management and if trained PAP smears or the new Liquid based cytology
Surgeries would be reviewed periodically during the year but definitely had a annual review where lots of things where taken into account like prescribing
I understand. But you will have to figure who will pay for what. What I see that will ensue is how horrible OUR system is compared to everyone who has NHS, but yet can only compare the LEVEL of care..and not the finances that supports it.
It's all encompassing and is the basis of what is trouble OUR own system now.
With absolute respect Jo I think you are perceiving intent that was not there. I am genuinely interested in worldwide information on how healthcare is provided and the pro's and con's of this. No one system is perfect but this forum gives us an incredible opportunity to learn from colleagues who's systems work differently to ours.
I'm sorry but I fail to see how that is an invitation in any way as to how much trouble the US system is in.
I am not out to attack any one healthcare sytem I am sure they are all with their benefits and flaws what I want to do is learn, not point fingers of blame or accusation. I also want to apologise as I have obviously touched on a sensitive issue in my size 7's and I genuinely would not want this.
Can I add a thankyou to Sharrie and Silverdragon for magaing to make sense of the NHS which is something I have always struggled to do :)
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
the uk system, the nhs was founded in 1948 by aneurin bevan. it was founded on the core principles that the health service would be available to all and funded by taxation, that way people would pay into it according to their means. (this is our national insurance which i believe sits at about 11% of your earnings)
the government sets our targets of what we should be achieving, so things like waiting times for treatment are fixed and hospitals have to achieve them. what happens if you don't? funding is reduced? or do you get shut down? for non urgent cases the target is from your initial referral to treatment is 18 weeksif you started off with a virus that has a potential to become more...18 days seems a long time to wait. so if you have a hernia that needs repairing for and your general practitioner refers you to the hospital today you ca expect to have your operation by june, for urgent of cancer patients the time for referral to treatment is 31 days.
generally speaking and from a big city perspective, patients in this area has a minimal waiting period to see a specialist. i can say for urgent cases--a few days to a couple of weeks. that's from a big city perspective though.
as far as clinical decisions go, the day to day decisions are made by the clinicians, although there are a few treatments that we do have to ask permission for such as vac therapy because of the cost, this is assessed by our wound care nurse who if she feels it is beneficial will authorise treatment, the funding is never refused providing this nurse approves it. emergency targets are also dictated by government so that no patient should wait longer than 4 hours in the emergency unit for treatment.
we have an organisation called the national institute of clinical excellence (nice) who produce clinical recommendations for treatments, these form a big part of our clinical policies, so they have hypertensive management guidance, management of dyspepsia, and recommendations for cancer treatments (there are lots more) the government will use these to tell us what we are allowed on the nhs, however nice is run by clinicians who look at the best evidence when drawing up their guidance, this is where you will find the news stories about patients who have been refused cancer treatments, it is usually because nice does not feel that the treatment has sufficient evidence supporting use, they look at the clinical benefits, numbers treated and cost of the treatment to establish if it is the best use of nhs resources. so...people are refused based on their prognosis. i have to get used to that idea. on the one hand, it sounds very financially appropriate--on the other hand, nice is playing god.
ok then that's the facts and figures, now the reality.
i think that we do very well with our emergency care, the acutely unwell are treated very quickly and we are closely monitored on things like door to needle time etc, the pre-hospital care is also monitored in a similar manner. if you present at the emergency unit with a mi you will be in an appropriate unit within the hour receiving treatment. as an aha accredited hospital system we are a heart and stroke hospital as well. we follow the same evidence and we have the same protocols. there is no age basis on this, however.
we have made huge improvements in waiting times and patients are getting operations sooner, i like this and think the targets have improved care, especially for our cancer patients. we have excellent health promotion and disease prevention programs run by our primary care services who are paid extra for achieving things like normalising blood pressures, making sure that diabetics are monitored and are well controlled, we have routine breast screening for over 50's and mens health clinics, smoking cessation, obesity clinics. the primary care doctors will be rewarded financially for these initiatives.i think this should be a priority in our healthcare system, and our hospital (mine as i can only speak from my own) is promoting this independent of government oversight.
however i do feel that sometimes we can compromise care on the wards to support our emergency patients, when eu is full to bursting we have patients on trolley's put onto wards, the nursing staff are then encouraged to discharge patients quickly to make the extra capacity and i do feel that we sometimes rush our patients to make sure we meet the targets.we are not obligated to do this. patients are discharged when appropriate. we are always in fear of litigation. i know that noone wants to wait in eu for longer than 4 hours but i struggle to justify pushing a patient with an abscess who could be drained on the unit to a ward to make sure that these are met, wonder if sometimes the targets overtake clinical need, not all of the time but sometimes.
the nhs is chronically short of cash, the organisation i work for is millions overspent so we are constantly asked if we can cut resources,this also translates to compromising care. as a magnet hospital, we do not do this. we can also afford --being a private not-for-profit hospital--not to have to do this. we, again, are also in fear of litigation so we are always aware of the potential for compromise and we avoid the pitfalls as much as possible. not recruit to help reduce this deficit. this means that things like overtime and getting agency nurses to cover sickness or absence is very difficult, meaning that the staff already under pressure are working short handed alot of the time. even though we are not a union hospital ( i am glad we are not--the big unionized hospital up the street is getting ready to "lay-off" people, we have specific labor laws to follow and we can say no to overtime. my hospital does not mandate overtime, except in times of disaster.
i think that there is a great deal of waste in the nhs, things like stock control, medications, we don't book them out to patients, so we aren't accountable for what we use,this should be addressed. why waste? we have a performance improvement team that handles this in our department. the more we save, the bigger the unit--hence staff, bonus can be. there is no compromise with patient care. it's about things we can control--such as minimal equipment loss, re-utilizing office supplies, etc., we do not compromise patients ever. i wonder if we had to justify why we are opening a packet of 10 gauze swabs rather than a packet of 4 we could reduce waste, but because patients don't pay for treatment we don't monitor what is used for what patients. things like controlled drugs are closely monitored.
our health and social care systems work independently, which means that often we have patients in hospital awaiting social care input before discharge. there appears to be a chronic lack of facilities for the patients who are not ready to go home but not acutely unwell so they sit on the acute wards waiting to either get better or for a transitional care bed to become available. we have private facilities that patients/families must either wait for--should insurance be paying, or families pay out of pocket for private care. access to social workers takes quite a long time, which again can delay discharges and then there is the discussion about who funds the care in the community is it health or social responsibility, again this takes time and delays discharge.
i've always lived and worked in a country where health care has been paid for by taxation, and i am not sure i would want it any other way, but i do wonder if we paid for health care differently would our expectations be different.there is no way to really be sure unless/until you live in something different. our patients come to hospital knowing that staff are overworked and busy, you wouldn't tolerate this in a shop or restaurant but we accept it in our health care and i don't think we should. americans in general, and even in this part of the country don't know the meaning of "delayed gratification". they are the most entitlement prone, and impatient types. but at the same time, they can choose where to go--especially those with private insurances--so yes, we do treat them nicely and with due respect. we are also afraid of lawsuits.i would like to see that our patients are treated as customers rather than patients and with that in mind staff the wards appropriately to make sure that our customers needs are met.
there are variances within england, wales, scotland and northern ireland as to what you get on the nhs, all medical care is provided in all regions but in wales and i believe scotland prescriptions are also provided however in england you have to pay a nominal amount to fill a prescription. we pay for dental care (there are nhs dentists but we still pay for the care provided and it is getting more difficult to find a dentist that provides nhs care for adults. children are covered with all dental care, we also pay for opticians but those who are claim benefits (unemployed, disabled, elderly and children) get free optical care.
even though america's system is imperfect, being an american--i am one of those who will not wait. so, ike you, i'm not sure i would be so quick to change everything about how we are now. many things, yes. but not all.
there you go, my overview of the nhs.
thank you for the information--p.s. please forgive me for the grammatical errors--very sleepy =)
"So...people are refused based on their prognosis. I have to get used to that idea. On the one hand, it sounds very financially appropriate--on the other hand, NICE is playing God."
It's not a matter of an individual's prognosis -- it's a matter of which treatments (medications, procedures, etc.) have been proven to be effective and which haven't. The NHS doesn't want to pay for treatments that have been shown to be ineffective in research -- evidence-based practice. It's a buzzword here -- in the UK, they're actually doing it.
Specializes in vascular, med surg, home health , rehab,.
Having worked in and experienced both systems, my conclusion is both systems are fatally flawed; I see daily in the US, patients who have no insurance or bad insurance given a raw deal. I work with people well into their 70's who have to work to continue medical coverage for their meds. I see pts patched up and sent on their way, all of us knowing they have no means to buy the meds or pay for follow up appointments. Off the census, next doc on calls problem. I see pts who know they will be hounded by collections agencies because they got sick after they lost their jobs, were unemployed and had no way to buy insurance. In the UK, I saw waiting lists that just went for not months but years in some areas of the country; a system overwhelmed not just by its own tax paying citizens, but any member of an EU country, or illegals that just aren't held accountable,or even verified, that end up costing the system so much money. "Are you a citizen?" if the answer is yes, well ok then. Free pass; amazing but its happening. As for most UK citizens, they pay the price in taxes, and in poor care. I can't say hand on heart, either system is good; I can say If I need a CABG, I will take the US, with the UK bills. There has to be a middle ground. Cut the waste, cut this "me first, I have cash" crap and get on with creating a system where responsiblity counts and people have access to affordable healthcare. Yes, it might cost more. But when I go to bed at night, and find myself deathly ill, money should'nt be the first concern I have. I had a US pt in a car accident, head injuries, a week on a neuro ICU; her dad came and they billed him 400 pounds; in the late eighties; They were afraid to give him the bill. He paid, so happy as as he said, at home this bill would be in the $20,00 and then some. Had he refused to pay....he'd have taken his daughter home anyway. Thats the difference.
Hmmmm. N.I.C.E. playing god "evidence based practice"
Hmmmm Insurance company playing GOD corporate bottom line
I choose NOT to have my health/my life determined by the corporate bottom line...
family member waited > 2 months to see (decent md for torn acl etc, etc,) and >2 months for surgery. "urban" maine
my spinal surgery approved but not paid for .....
I have worked in LTC/subacute I have seen way too many pts discharged to our care WAY before they are ready to be discharged (something to do with insurance targets - eh)
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
"So...people are refused based on their prognosis. I have to get used to that idea. On the one hand, it sounds very financially appropriate--on the other hand, NICE is playing God."
It's not a matter of an individual's prognosis -- it's a matter of which treatments (medications, procedures, etc.) have been proven to be effective and which haven't. The NHS doesn't want to pay for treatments that have been shown to be ineffective in research -- evidence-based practice. It's a buzzword here -- in the UK, they're actually doing it.
Here is my question then:
If the case is that medical treatment WOULDN'T extend an individual's life more than a few months-- and the evidence show that is the most ONE can get from it--will it still be offered, if the cost outweighs the benefits? Will NICE say no based on statistics alone? Or do they consider other factors?
If that is the case, who gets to say to the family that their parent/sibling/son/daughter isn't worthy of that treatment? Who gets to pull the ethical card for this?
I hate to quote Sarah Palin because she is not exactly the best resource of this type of dilemma, but it sounds very "DEATH-PANELLY." to me.
As JoPACURN mentioned, she/we who work in the US Health Care System, have many concerns about being sued.
If our US Health Care System becomes run by the Government, where will patients go to complain about the care or lack of care. You can't really sue the US Government--can you?
In other Health Care Systems (Canada/ UK) how are complaints handled?
If the case is that medical treatment WOULDN'T extend an individual's life more than a few months-- and the evidence show that is the most ONE can get from it--will it still be offered, if the cost outweighs the benefits? Will NICE say no based on statistics alone? Or do they consider other factors?
If that is the case, who gets to say to the family that their parent/sibling/son/daughter isn't worthy of that treatment? Who gets to pull the ethical card for this?
I hate to quote Sarah Palin because she is not exactly the best resource of this type of dilemma, but it sounds very "DEATH-PANELLY." to me.
I'm not in the UK or personally familiar with the NHS -- just what I've read about it, and healthcare delivery systems in other countries are a long-standing interest of mine (so I've read quite a bit) -- so someone who knows more about this, please feel free to step in and take over ...
BUT --
My understanding of the NHS system and NICE is that NICE has nothing to do with any individual and the treatment s/he does or doesn't receive -- NICE makes decisions for the entire NHS system of what treatments and procedures have been proven effective and are therefore available within the NHS system, and which treatments or procedures the NHS will not offer because they have been shown to be ineffective. It is entirely between the individual and her/his physician what treatment someone does or doesn't get of the treatment options available within the NHS system.
It sounds to me like you're trying to turn this into a Palinesque "death panel" scenario, but that's not what it's about. It's about the NHS doing what they can to ensure that taxpayer money is not being spent on treatment that has been shown to be ineffective in general, across the board -- not that it's not cost-effective or worthwhile to provide a particular treatment to a particular individual.
PostOpPrincess, BSN, RN
2,211 Posts
I would like to defer to you. Please go ahead....