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 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...

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...

Typical Danish Weekend

RPOTD:



The fact that this saying is used by physicians everywhere for some reason makes me feel better about the future of the world.

Another thing that makes me feel optimistic: Denmark. Sometimes all the right-wing opinions out there somehow wiggle their way under my skin and make me start to question some of my core political beliefs: is nationalized healthcare really the way to go? are higher taxes for the wealthy just a punishment for doing well? is a welfare state just an invitation for people to be lazy? is Obama really orchestrating a systematic dismantling of America we as we know it just for his own political gain? Okay, so I never actually entertain that last one, but the Right is just yelling so loudly sometimes that I find myself wavering. But 4 days in Denmark was enough to confirm my belief that moving towards socialism is a good thing. This isn't meant to be a blog about socialism, or the welfare state, but it is going to talk about the awesomeness of Denmark, with hints about what enables it to be so awesome (spoiler alert: the answer is usually "taxes").

So first some background: why did we go to Denmark? it's not because we love pickled herring or pork, that's for sure (although I do love pickled herring). I studied abroad in Denmark in spring 2003 (if you can call that weather "spring"), and in addition to getting to love Copenhagen, I also lived with a really great host family and we wanted to visit them. Also, since I was there my host sister had a baby, and I wanted to meet her Danish toddler (verdict: just as cute as most toddlers, but speaking Danish!).

The very short version of our weekend was that we spent Friday in Copenhagen and stayed with Catrine (one of my host sisters) and her boyfriend Christian that night. The next morning my host parents, Ghita and Henrik, brought breakfast over and we all had a nice breakfast together (Oh, how I miss Danish breakfast! Dark bread, rolls, several kinds of cheese, jam, chocolate, butter, occasionally soft boiled eggs, and tea.). We spent the rest of the weekend staying with them in the small town of Jyllinge, on the eastern shore of Roskilde fjord, exploring the surrounding area, and visiting with Camilla, Kasper and the above-mentioned Danish baby. On Monday I went to work with Ghita for the morning, who is a nurse in a primary care clinic (but more on that later), then we spend the afternoon back in Copenhagen before flying home. It was a great weekend!

Okay, now on to the meat of the post, which is my impressions of Denmark. First, it was really interesting for me to be back in Denmark as an adult. When I was there before I had never lived on my own, didn't really think about politics at all (I think most of us were trying not to in spring 2003), hadn't traveled much, and probably didn't fully embrace the experience because I was thinking of a boyfriend back home. Also, it was always cold and windy, so I literally spent the first 3 months with my head down. This time I was much more aware of some of the things that make Danish people think they live in the best country in the world (*especially* better then Sweden), and I started to think about why those things are the way there are.

1. Bikes. It is impossible to talk about Copenhagen without talking about bikes. They are simply everywhere, and ridden by everyone. There are a few factors that make this possible/encouraged. One is that it is flat. Really, really, flat. So you can easily bike across the city without breaking a sweat (okay, so it's a small city, but still). Also, cars are expensive - really, really expensive. Or more accurately, the car is the normal price, but you pay around %200 in taxes. Many jobs will provide you with a company car, but for everyone else cars are just too expensive (though starting soon you will be able to buy an electric car and avoid the taxes, as an incentive to buy an electric care, which may be "powered" by wind). But importantly, the city doesn't just hang people out to dry: biking is a very viable option in cities because there are bike lanes along all the major streets. And when I say bike lanes, I don't just mean a magical line of paint that is somehow supposed to defend bikers from massive SUVs and MBTA buses. I mean an elevated, smooth lane on the side of the road. Like a sidewalk for bikes. And of course, there is a separate sidewalk for pedestrians. Copenhagen also boasts a good bus system, a train system, and most recently a sleek, fast metro system that is currently being expanded. All of this means that there is a minimal number of cars in the city, which makes it much more pleasant to walk around.

2. Family support. My host sister Camilla is getting her master's degree in urban planning/landscape architecture, rebuilding her new fixer-upper house, painting beautiful paintings, making homemade jam, and raising the adorable danish child along with her partner Kasper. And she seems to be doing it with ease. How is this possible? Mostly it's her own dedication and focus, but it's made easier by the country she lives in. For one thing, when both she and Kasper were in school, childcare was free. Free! At whichever local daycare they wanted! There is an income level under which childcare is free, and unsurprisingly the income of two students is below that level. Which is not to say that they don't have income: in Denmark college tuition is paid for by the government, plus students get a stipend to pay for their living expenses. Many students also work a few hours a week so they can have some spending money, but isn't that amazing! No student loans! No $150,000 of debt if you want to be a doctor! Another factor that makes it easier for women to have children during school is that their concept of the usual path of education is much more fluid. Many people take a gap year to travel or volunteer between high school and college, or maybe go to one year of another kind of school. It's much more acceptable to take time off while you take classes, or just delay the progress of classes. So Camilla thinks it was wonderful to have a child during school, because she could just take time off from classes then restart when she wanted.

This is a big deal for a lot of reasons. It makes sense to make having children compatible with education, so women who have children on the younger side are not discouraged from continuing their education. And conversely, it makes sense to make it easier for women, should they want to, to have babies when they are younger. It's very clear that there are health problems that arise when women who have children later in life, and it's harder for them to get pregnant in the first place. Now, there are many reasons that people in the US and Western Europe are having children later that are unrelated to education and cost of childcare, but it is certainly a big factor.


3. Unemployment support. This was relevant while we were there, because Henrik's company was in the process of laying off a 3rd of their employees. This was very upsetting to him, because as it's a company of 62 people, he knows all of these people personally. And he had to do some of the laying off, which, while better than getting laid off yourself, still sucks. But this reminded me of a Planet Money piece on Denmark that we heard back in the spring. If you have time you should listen to it, but if not, I'll give you the unemployment-related summary. In Denmark, unemployment benefits are high, and they last for a long time, so 1) people are less concerned about losing or leaving their job, and 2) companies are less concerned about having to lay people off, so they're more likely to take a risk on hiring a bunch of new people as soon as they have the capability. Oh, also, if you lose your job you still have health insurance because the government provides it. So people in Denmark, by the end of their working lives, have usually worked more jobs than your average person in the US, either by choice or not, but they haven't had to stop going to the doctor or work 3 low-paying part time jobs to make up for their lost income. So people may call is Socialism, but freedom to not be afraid to leave your job, for companies to not be afraid to hire people quickly...that sounds like the free market to me.


Okay, that's all the economic-related stuff I wanted to talk about, but before I move on I of course have to address the elephant in the room, which is how all of these nice things - the flashy, expanding metro system, the well-maintained bike lanes, the tuition and childcare support, the health insurance, and unemployment benefits are paid for. Taxes. Massive, massive taxes. The 200% tax on the car is a good example. They also have a 25% VAT, and their progressive income tax system maxes out around 50%. Obviously there are some people in Denmark who are less than thrilled with this system, but as the Planet Money piece suggests, most of them are pretty okay with it. It's just the Danish way of life - you get to keep less of your income, but most of it comes back to you in benefits. And you get the satisfaction of knowing that the economic systems of your country does not result in people living out of their cars or not being able to afford to feed their families when they lose their jobs, or get pregnant while they're still in school.


In addition to all this, there was just a certain *something* I felt on this trip to Denmark that I couldn't put my finger on. Scandinavians have a reputation for being not very friendly (How do you spot an outgoing Swede? He looks at your feet.) But our experience on this trip was the opposite. I was impressed with just how much my two host sisters had grown up to be just as gracious, honest, caring and curious as their parents. And I think if you asked them they would say that they are just a typical Danish family. There was always a plentiful stream of food and tea and snacks, which is just how I remember it from when I was there (but incidentally, they are all in great shape) - even at the primary care clinic they schedule a 30 minute break in the middle of morning so people can get caught up on their work and appointment, and during this time someone brings in a loaf of fresh bread and a block of cheese. Everyone at the clinic was really eager to meet us - Danny sat in the conference room and read, and he says that he probably spent a 3rd of his time talking to the doctors who would pop in to chat with him (mostly one doctor, Hans Christian, who had just been on a trip to the US recently). Also, people were very interested in Danny's dissertation topic, as Denmark has a lot of parallels to England in the current state of religion. They really wanted to discuss the issue, to hear what he was learning. We talked about this a bunch over drinks on Friday night, and I think the term "path dependency" was thrown around, and not by one of us. Did I mention that they all speak really, really good English? Catrine goes to Copenhagen Business School, where all of her classes are in English - she even takes notes in English!

Beyond the friendliness to us, there is just a certain embracing of life that I found very impressive. They live in a cold, dark country, and they've really made it their own. Fashion is focused on thick tights, long wool scarves, multiple layers, and big sweaters. I've never seen so many stylish people riding bikes in bad weather in my life! They even manage to look stylish in outwear, thanks to the prevalence of Helly Hansen jackets. They put a lot of effort into decorating their homes to create a welcoming, relaxing and comfortable atmosphere. One of the first things my family explained to me when I got there was that "Italians all have nice verandas, we all have nice living rooms." They light candles as soon as it gets dark and have them all over the house, something I had forgotten about but was immediately reminded of how nice it is. All of this works together to create the feeling that the Danes describe as "hygge". They insist that there is no appropriate English translation, but the closest thing is "coziness", maybe with a sense of "togetherness". There's also a real sense of national pride, and not a snobby national pride like of other European countries, but a pride in what Denmark has accomplished and created. They're proud of everything from traditional food, to the history of the Vikings (except maybe not the pillaging), of the many kings Christian and Frederick and their contributions to the country, to the ultra-modern danish design and architecture.

I'm not sure how much this general happiness is related to the so-called welfare state (or maybe the general happiness makes them a more gracious population who is willing to support a welfare stats?), or maybe the two are unrelated. And all I can say is, I want to go to there.

Academia, England-style

Random Photo that Danny thought was funny:

Oxford may only be the 6th best university in the world (thanks, Stephen, for posting the link), but it's still an amazing place for a weekend trip and conference! Thanks to my cushy connections at the LSHTM, I got to attend a Health Policy conference earlier this week, held at Madgalen College in Oxford. The conference was Monday and Tuesday, but Danny and I headed out on Sunday morning to see just how Oxford compared to Cambridge (which, incidentally, just leaped over Harvard for best university in the world). Although the hands-down verdict is that Cambridge is better (I mean, who punts from inside the boat?!), we had a great time. Highlights of the visit included:

- Visiting Christ Church (which is a college, not a church, although it does have quite a large church), where some scenes from Harry Potter 1 and 2 were filmed, and where Charles Lutwidge Dodgson was inspired to write Alice in Wonderland. Alice was the young daughter of the dean of the college. Every night after dinner the dean would leave via a hidden door and back staircase - the white rabbit was based on him. Alice also had a cat named Dinah who would sit in a tree next to the library.

- Listening to bees. Just so you're assured that Oxford does have a hippy-dippy side, we visited a socio-ecological project where a guy has set up 2 bee hives, with a stethescope in each one so you can sit and listen to the bees doing their thing. It was pretty cool.

- Cream tea

- Dinner at one of Jamie Oliver's Italian restaurants. Tired of going to pubs and finding just one veggie option, we splurged for some home-made Italian goodness. And it was good.

- The Ashmolean museum: art and old things.

- The Museum of the History of Science. Lots of beautiful, hand-made astronomical tools that I don't understand, the original 1940 journal describing the use of penicillin (not that long ago!), several of Marconi's first radios, and a chilling display of the first anesthesia delivery system from the 1840's next to a bone-saw kit from the late 1700's. Ouch.


But it wasn't all fun and games and tea (although we did buy a new game, and we did drink a lot of tea). We were also there to learn. While Danny went to the Bodleian library to read the records of the conservative party, I began in earnest my foray into the social sciences. It was really great to think about the more large-scale aspects of health, rather than just how we treat diseases. Topics ranged from the fairly straightforward (do policies to include patients in safety efforts work, and what determines whether patients want to get involved) to the obscure-but-thought-provoking (focusing on social governance and the fate of all humanity rather than politial and economic gains).

The keynote address happened to be by Ted Marmor, on the recent health care reform in the US, and how we managed to get a "Republican style" plan that no republicans voted for (answer? US senate structure. and some other stuff). But he is hopeful that some of the new laws regarding private insurance may pave the way towards more universal, if not single payer, health care.

Another point that was driven home in this conference is that in the UK, health care policy changes all the time. Yes, the NHS has been in place since 1948, but they (politicians) feel the need to make some slight change every 2-3 years - changing the details GP contracts, changing public health priorities, changing the flow of money. All of which of course means that there's very little time to evaluate policies, and everyone does so under the assumption that they will just change in a few years away. And doctors have just gotten used to the idea that while the policies change constantly, once the dust settles they will go back to practicing medicine as usual. Whether that will be the case with the new White Paper, though, is anyone's guess. But more on that later. For now, it's off to Salzburg!

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!