Primary Care Across the Globe! part 2

2. Luton. When I say the Detroit of England, I mean that it used to have several industries based in the area (car manufacturing and hat making) that have since left. What they've left behind is a huge problem with unemployment, homelessness, and drug abuse. But what Luton has the Detroit doesn't, is a large influx of recent immigrants. While most of them are young and relatively healthy, their presence adds an added complication to being a GPs in Luton, because many of them don't speak English (and for GPs to learn a bit of Urdu AND Bengali AND Arabic AND Polish is quite a tall order), and as I recently learned, because many of them are young and healthy, there has been a huge demand for more maternity services. And between the homeless population and the immigrant population, this clinic has decided that a dedicated TB nurse is necessary. oy. But this is what I love about general practice - you have to be ready for anything.

I shadowed a GP for the morning, then spent the afternoon chatting with some folks at the clinic - the practice manager (deals with $$ and staffing issues), the information system expert (deals with the medical record), his trainee (the equivalent of a 2nd or 3rd year primary care resident), etc, and there were some interesting things that I thought were worth sharing.

Electronic medical records. They're becoming the norm in the US and the UK, but for the most part they're only available within the clinic or hospital system you practice in. Well, England is making a go of a national computerized medical record - the Summary Care Record. So far, the plan is that it will contain some demographic information, a list of medications, and a list of allergies. So, the story goes, if you were rushed to the Accident and Emergency (ER, for us) anywhere in the country, the doctor could easily see "Hey, she's on insulin!" or "Hey, this guy had heparin induced thrombocytopenia!", even if you were unconscious and had no one with you. This ideal has been talked about for a LONG time in the US, but we're not really getting any closer to it. People are very concerned about privacy and security of records, which is reasonable, and it's obviously imperative that security be a cornerstone of the project. That fear is here as well (there is the option to opt out of the summary care record, just like you can opt out of chlamydia screening), and I read a recent letter in the British Journal of General Practice, by a GP, urging all other GPs and patients to opt out due to security concerns. nice. So it will be interesting to see if/how England really pulls this off, if they will be adding more information to the record in the future, and if America will follow suit.

Private insurance, and why you might get it. All right, I'll admit it: people here do wait longer for non-emergency surgeries, and sometimes there are more stringent criteria for who is allowed to have a procedure. The IT woman I was talking to gave the example of her father-in-law. He was old, he wanted a hit replacement, but the NHS wouldn't cover him because he was too overweight. I guess the assumption is that a hip replacement isn't absolutely necessary, and more importantly, being overweight that would greatly reduce his chances of a good result from the surgery (recovering from a hip replacement is a lot of work!). Now, some people would argue that this is the government making a moral judgment, that maybe the NHS is saying that this person got their hip problems because they are overweight and now they don't deserve a replacement. Some people would call it rationing. The NHS, I believe, would argue that they are just trying to only pay for procedures that will lead to better health outcomes (imagine that!). But at any rate, the father-in-law was able to buy private insurance that would help him pay for his surgery, and soon. Because he had just purchased the insurance for the sole purpose of the surgery (wait, isn't that an underlying condition???), he had to pay more out of pocket for the procedure. If he had been paying for a little extra insurance for many years, he would have paid less for the surgery. This whole situation with private insurance does lead to a situation where the wealthy get more access to some specialty care, that's true. But the point of the NHS is that everyone receives basic, necessary, high-quality care for free or cheap.

Foreign MDs. At Swarthmore, there was an orthopedic surgeon who working in the dining hall. No joke. He was from South Asia, and he was serving up our tacos, pizza, and other delightful entrees of college dining while he studied for his exams to get certified as a doctor in the US. There was an Indian resident on my surgery rotation who was repeating most of her residency (!!!) in the US so she could practice there. Now, I don't know what the exact rules are for coming to either country, but talking to this trainee (who was from India), it was clear that it is fairly straightforward to come to the UK to practice from other countries. She has started her residency in India, then came to the UK and started right up again where she had left off. Maybe it's because their education systems are similar, maybe it's Colonial guilt, maybe it's the honest recognition that doctors from other countries can also have exceptional training, but I was stuck by the simplicity she recounted in getting qualified as a doctor in the UK vs. in the US. And this actually works out well in terms of having doctors and patients who speak the same language.

Lastly, I had lots of conversations with people about healthcare in the US. First of all, except for those people who have made a career of studying it, they have no idea what it's like (even most people in healthcare in the UK don't really get it. Who can blame them?). And when I explain it to them, they are horrified. People go into debt for medical bills? They had debt collectors calling them daily? 45 million uninsured? even kids??? I think that a lot of Americans imagine that the English are jealous of our fancy healthcare in the US, with our abundance of MRI machines and slews of specialists, but in my talking to people one thing has become clear: they would NEVER give up the NHS to have any of that. Just something to ponder as states amend their constitutions such that they won't have to follow the new healthcare reform legislation...