Primary Care Across the Globe! part 1

Okay, so across the globe is a bit of an exaggeration, but I did have the pleasure of observing and talking to people in three primary care clinics in two countries in the past month or so, and I have some thoughts. The first clinic was in our neighborhood, and I was there as a patient (just routine stuff). The second was in Luton, a city north of London which I now affectionately think of to as the Detroit of England. The third was in the aformentioned "Socialist" country of Denmark, where my host mom is a nurse in a GP clinic. We'll take them in order, and I'll try to keep this interesting to people who don't want to spend their lives studying primary care organization and delivery (which is I think all but one of you).

1. Parliament Hill Surgery (in the UK, "surgery" is both the profession of slicing people open, and the physical building in which doctors work) is just your average GP clinic in London. A handfull of GPs, two receptionists with dodgy mastery of English, and a few nurses who give flu shots, see patients with minor illnesses, offer smoking cessation advice, take out stitches, and follow-up with patients with stable chronic diseases like diabetes and asthma and hypertension (did I mention my mad respect for nurses? I have mad respect for nurses.).

There are a few notable things I got out of this experience (well, notable for an American, anyway). One is, and this is what many people imagine and fear when they think about "Socialized Medicine", is that you don't have unlimited choice of which doctor you see. In the US you are limited by who takes you insurance, and of course the extent of this limitation depends on what your insurance is. In the UK, you are limited by geography. In the original incarnation of the NHS, every GP was given a list of patients that lived around them, and they were responsible for the health of these people. Everyone on that list had to go to that local GP for healthcare (or, free healthcare, anyway). And if you needed the care of a specialist or a hospital, they would tell you where to get that care. As the system modernized, "choice" got added to the NHS. Now there are multiple surgeries that will accept you as a patient, but it is still limited: many clinic websites have a map of the area they serve, and you have to bring proof of address when you first show up to the clinic. There is now choice in specialist or hospital care as well, although if you live in a rural area that choice is probably more theoretical and real (but that's the same for any rural area, with any healthcare system).

In addition to having to give proof of address, you have to "register" with the surgery, which means going in and filling out forms. These forms, in addition to the standard questions one finds on registration form of all sort, include information about family history, personal medical history, as well as questions about smoking, alcohol, drug use, and the option to opt-out of routine chlamydia screening for women 18-25. I found myself contemplating whether I wanted to opt out or not ("Well, I'm really not at risk for chlamydia, but then again I want to be supportive of their public health efforts...") when I realized that I'm too old to be considered "high risk". Which I guess is a good thing? Anyway, it got me thinking about these written tools we use to screen for problems as diverse as asthma, depression and alcohol abuse. Even when problems can be quantified, as in alcoholic drinks/week, how do we pick a cutoff of 7 drinks/week for women as the difference between "normal" and "problem" drinking? I know, I know, these tools are validated, tested on a larger population, tweaked, and tested again. But despite the fact that screening tools like this fall into the realm of what I am studying this year (GPs delivering public health), filling out these forms for myself made me realized the impossibility of it all - how can we decide just from a form who might be depressed, or who may be in an abusive relationship? The answer, of course, is that these forms will never be the only method of diagnosis - luckily we still have caring, thoughtful GPs to care for our patients.

Whew, I guess that wasn't really specific to healthcare in the UK, other than the fact that the NHS loves for GPs to gather data about patients. In fact, the biggest quality measures (upon which hefty payments are based) for GP are just based on keeping good records of patients with chronic diseases and keeping up to date with regular health checks for healthy adults. But more on this later, if you're interested.

Okay, for both my sake and for yours, I'm doing to break this post up into 3 different posts about primary care. I should point out that you should feel free to ask questions about the UK healthcare system (or the American healthcare "system", for that matter), if you have them. After this series I promise we'll get back to the fun stuff, like cheese and beer.

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