Primary Care Across the Globe! part 3

Return of the random photo, this time from from the Queen's Wood (N10), last Saturday. Sadly, this is about as dramatic as the fall leaves are here in London. Growing up in the Northeast spoils one for fall colors!


Okay, this is the last post in the current series about primary care clinics. I did visit a 4th clinic last week, shadowing a GP I met at the Oxford conference on health policy, but nothing to report about that. Well, okay, two things to report. 1) It was awesome to see patients again! and to use my stethoscope! 2) It still gives me a thrill to be introduced to patients as "a visiting doctor from the United States", and to be able to provide "two doctors for the price of one," as she said (the price of one, of course, is £0).

But the main focus of this post is my experiences in Denmark, when I went with my host mom to the GP clinic where she works as a nurse. The clinic has 4 GPs and 2 nurses, all of whom were incredibly friendly and welcoming. Danny spent the morning reading in the conference room, and it seemed like one of the GPs was popping in every 20 minutes to chat with him, mostly about the only place in the US he had been (Boise, Idaho). I think I would be a pretty happy GP too if I had a 20 minute scheduled mid-morning break to enjoy a cup of tea and some fresh bread with cheese. Whether this is standard practice in Danish general practice or just happened at this clinic I don't know, but I could certainly get used to it. Just two main points about this visit.

1) The casual nature. I don't remember if I've mentioned this before, but no one in the UK wears a white coat. Not because they don't like to, but because they've been banned. The white coat, with it's dragging sleeves and lack of regular washing, essentially turns the wearer into a walking drug-resistant bacteria petri dish, and no about of gravitas is worth that. But it Denmark they take to a new level. Not only do they not wear white coats, or ties, but they are perfectly comfortable wearing jeans and sneakers. In fact, most of the male GPs were wearing black jeans and plaid short-sleeve button-down shirts. It was pretty sweet. The relationships between the staff and the patients was incredibly jovial and relaxed; I don't know how much of this is due to the Danish sense of humor, lots of longitudinal relationships, but some of it could be due to a lack of pretense that the doctors emitted (while still emitting confidence).

2) Freestyle, as needed health care. I think there is a fear in this county that with a government-run health care plan would come scores of regulations about the services that physicians have to provide, how often they have to provide them, and demands that patients "consume" health care in a certain way. And the UK is moving in this direction - all patients over 40 are expected to be seen once a year, and certain "screening" data is supposed to be collected (cholesterol, BP, weight, fasting glucose, etc). Of course, the ironic thing is that this is already the norm in the US, even without regulation. Because of the defensive and perhaps excessive way medicine is practiced in the US you can't walk into a clinic without getting a full range of vital signs taken (I just heard of a friend who had an EKG done as part of a routine checkup as a totally healthy 24 year-old!), whereas in the UK blood pressure is only measured if it is related to the presenting complaint (or now as part of scheduled screening or follow-up).

But in Denmark, which is even more of a scary Socialist country, these regulations are close to zero. No rules about how often you have to go in for a checkup (my host father hasn't seen a doctor in 20 years), no rules about checking cholesterol and blood pressure on patients that the doctor has no concerns about. At first I couldn't believe this. What about public health?! What about screening for "silent" diseases?! But I think the chart below, which I posted as a comment to an earlier blog, says it all:



Better outcomes for less money? Um, yes please. Interestingly, Denmark is "behind" much of the rest of Western Europe when it comes to life expectancy, so there is clearly room for improvement, but the point is that it's not lagging behind the US (in fact, it's marginally higher), and for much lower expenditure per capita. Of course, life expectancy is not the only measure of health outcomes, but I think it's a good place to start, no?

My point here is mainly that even within "socialized medicine", there is lots of variation in what a program can look like, and more specifically, it doesn't have to mean that the government is telling you or your doctor how to make every health decision. Besides, private insurance companies already do that, so it really shouldn't be such a scary idea for Americans...

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.

Stay with us...

Two can play at this game: The History of Primary Care in the UK

I hope that many, many years from now, I will be remembered this way too:


This post falls under the "Remind me what you are doing in London?" category. While Danny is off in the archives, I will be working in the Health Services Research Unit of the London School of Hygiene and Tropical Medicine (henceforth known as The Trop). As many have pointed out, the name of this school is just dripping in colonial history (though to be fair, hygiene and sanitation improvements do more for public health than just about anything). My work will be on a "scoping study" of England, trying to see how general practitioners (GPs) and clinics are providing health-promotion and disease-prevention services. But more on my actual project when I start in August.

For now, I am doing background research on the history of primary care in the UK, how primary care is currently organized, what exactly the National Health Service does, etc. Today I was poking around the website of the Royal College of General Practitioners, which like all good British organizations, keeps great public records of its own history. One of the most interesting things was a collection of letters from the early 1950s, when the College was first starting to take shape. Apparently there were already Royal Colleges of several other specialties, like surgery and obstetrics, but general practice was always considered too mundane or antiquated to share this status. When a group of GPs got together and started floating this idea, they got some really nice letters from other GPs around the country, with very poetic descriptions of why general practice was such an important part of the medical tradition, and why a Royal College of GPs was so important.

From one letter: "It is not popular to insist among doctors that the GP is first and foremost a healer and that his primary aim is to restore wholeness or guide his patients towards health. Health may be undefinable, but is not difficult to recognise if present." And from another: "The general practice of medicine could at this present moment be standing on the threshold of an intellectual renaissance."

Interestingly, this call for the RCGP came about because of the creation of the NHS in 1948. The NHS dictated that GPs were all responsible for a health of a particular panel of patients in their geographic area, but did not allocate any funds for these doctors to meet the needs of their new patients. Underfunded and overworked, GPs started to deliver poor-quality care and became completely demoralized. They could not encourage any high-quality young physicians to go into the field, and there was some question of whether the profession would survive.

Sound familiar??? This is shockingly reminiscent of the "perfect storm" that Cambridge Health Alliance doctor Somava Stout talks about in a recent CNN interview. Lots of new patients getting insurance and entering the patient population (good!), but still difficult to attract young physicians to a career that involves piles and piles of paperwork and will not pay back their student loans in any reasonable amount of time (bad!). I don't think that primary care in the US will spiral like it did in the UK after the NHS came into being, but big changes in reimbursement, plus a culture change around medical education to re-invigorate medical students interested in primary care, are both necessary if we are going to weather this storm. Find out what Primary Care Progress is doing to help!