The Anniversary of the NHS and Scotland Forever

July 4th may be an important day in U.S. history. However, July 5th is an important day in British history.  The British National Health Service (NHS) turned 70 on July 5th, 2018. As the U.S. political left publicly embraces socialism, and as more Americans walk away from useless low-cost Obamacare insurance plans that don’t actually pay for anything, or go without care because they have $5,000 deductibles, there’s more support for socializing healthcare. It’s even been suggested that the Affordable Care Act was designed to implode like a carefully controlled building detonation – so that a single payer system would be the logical fix.

There was talk about socializing medicine in the 1980’s when I was in medical school. That’s why I decided to spend 2 months in Britain during my 4th year to see how socialized medicine worked. I don’t want to imply that the 2 months I spent at the Western Infirmary in Glasgow, Scotland 34 years ago makes me an expert about this topic. Both “The Western” and the NHS have changed a lot since then. However, it gave me a cultural and economic perspective that might be worth comment.

In 1984, The Western Infirmary still used large Victorian wards that held more than twenty patients, with curtains that could encircle each bed. It felt like a set for a World War I movie. This configuration made “ward rounds” extremely efficient for the medical team, but would have made enforcing today’s HIPAA laws impossible. On the plus side, on my first day, I arrived at 6 AM only to discover that the working day started at the very civilized hour of 9 AM. Additionally, the entire world stopped at 3 PM for tea. I think they might stop CPR for tea. If I could import one thing from the United Kingdom – it would be that everyone from the most senior physician to the housekeeping staff (including the patients) – took a mid-afternoon break and for a few minutes, exchanged pleasant conversation about something other than illness. Conversation was tremendously witty, assuming you could understand it. I went to Scotland laboring under the mistaken impression I spoke the language. I quickly learned the useful phrase, “Can ye talk mair slow because a dinna unnerstaun,” when a frustrated man finally asked me, “Lassie, e want tae write it doon fur iz?” (Do you want me to write it down for you?).  The patients were beyond wonderful – colorful, hard-working, and full of humor.

In the U.S., 34 years ago, it was still a bit unusual to be a woman in medical school. However, in the UK, it was already common. I was surprised to discover that as a 4th year medical student, I was already older than most of the registrars (roughly equivalent to a “resident”). That’s because in the U.K, they start medical school after high school (secondary school). They get 2 years of academics and 3 years of clinical training at a teaching hospital to become a doctor, but they degree they get is different since that’s effectively their undergraduate degree. Compared to the U.S, it’s not that expensive to go to medical school in Britain. In the U.S., the median debt burden for graduates of public medical schools is now more than $200,000. This is a huge problem since physician salaries are plummeting, making it harder for doctors to pay their school debts. In contrast, all leading British medical schools are state-funded because they exist to train doctors for the NHS. Medical school isn’t entirely free, but it’s cheap compared to the U.S. In the U.S., Bernie Sanders generated a lot of excitement with the idea of “free tuition,” but at least in the U.K, when the state is paying for most of your education, the state decides who gets to have it. According to Google, in 2018, in Britain, only 8% of medical school applicants were admitted. It’s also very hard to become a medical specialist there.

I learned how to perform a physical examination in Scotland from some of the finest clinicians I’ve ever met. They were able to demonstrate physical findings on patients with very advanced disease because while everyone could access primary care, access to specialists or specialty procedures was difficult. In the 1980’s there was one CT scanner in the entire city of Glasgow, and if you wanted a blood test you had to draw the blood yourself and walk it to the lab. In 1987 I visited a friend doing a fellowship in London. To get laboratory results at night, she stood on the street corner with the blood samples so a taxi could pick them up to take them to the hospital lab that was open.  On the other hand, I never saw a patient go into iatrogenic heart failure from IV fluid overload because at least back then, hardly anyone had an IV. If you wanted a patient to have an IV, you (as the doctor) had to start it yourself and then be responsible for managing it.

Back then, there were a LOT of registrars on the wards. That was necessary in part because doctors did some of the work the nurses do in the U.S. However, another reason is that there was always a registrar out “on holiday.” They got 6 weeks of vacation a year. Yes, you read that right – six weeks. It takes a lot of extra staff to make that possible. In contrast, I was about to start a residency known for its brutality in which I worked more than 100 hours a week and, at least in the first year, was never allowed to take the 2 weeks of vacation I was supposed to get. While it’s a good thing those days of abuse are gone in the U.S., by the time I was ending my academic career in 2013, I had become more of a nanny to the residents than an attending. Attending physicians in the U.S. now routinely do the residents’ work, because rigid laws prohibit overtime by even one minute. I noticed that the residents exhibited a growing sense of entitlement, often complaining that they should just not have to work nights or weekends. I wonder why is it that the simple process of creating what seems like reasonable “protections” changes psychologically what it means to be a physician? Interestingly, there’s now a serious physician shortage in the U.K. Apparently, the downside to having a subsidized education is that you don’t have to work when you are done. Without the “focus” that debt creates, women stop practicing as soon as they begin having a family, physicians retire young, the work day is shorter – all of which add up to the patients not being seen. It’s been proposed that physicians be required to work a minimum number of years for the NHS to pay back the cost of their training – a proposal that has created an angry outcry on the part of young physicians.

Meanwhile, at the Western, there were patients post myocardial infarction on vasopressors on the open wards with no central line blood pressure monitoring. Periodically one of us would just go take their blood pressure with a cuff and a stethoscope. They didn’t go to the ICU if they were over 65 years of age, because statistics had shown that going to the ICU after an MI at 65 did not increase one-year life expectancy. They were making “evidence based” decisions in the 1980’s, long before we had heard of it. Since then, the National Institute for Healthcare Guidance (NICE) has analyzed many therapeutic interventions from the perspective of “quality of life years” and has effectively established the maximum price per year that is reasonable for the NHS to pay for things like cancer treatment. They have to do this because the NHS is in deep financial trouble. At least the NHS is honest about the fact that they are rationing care. We would be better off if we were similarly honest about Medicare. Medicare will be bankrupt in 2026 and while conversations about quality are important, a focus on quality alone won’t save Medicare. We are going to have to make painful decisions about what we don’t pay for and actually call it rationing.

From the standpoint of the physician, socialized medicine could be a sweet deal – sort of. As long as your education is financially subsidized, you don’t have to worry about getting sued, you are guaranteed a job with banker’s hours, six weeks of paid vacation a year, maternity leave and sick leave – what’s not to love? I’m not sure we could pull that off in the U.S., but that’s what it would take. The downside is that there’s no motivation to worry about patient satisfaction or excel at anything. If you work harder than your peers, you won’t have anything to show for it. From the perspective of the patient, it means long waits to be seen by a specialist or get an operation, and deteriorating buildings. As a result, patients who can afford it purchase private insurance. In other words, the thing that enables socialized medicine to limp along in the U.K. is a parallel private healthcare system.

I am still in contact with friends I made in Scotland more than 30 years ago. What I discovered was that you get the results you design a system to achieve. If you build a system in which people have no incentive to work harder or better, they won’t. You might argue the U.S. has produced the exact opposite, creating a medical culture that is entirely too profit driven and I can’t argue with that.  Every system has to account for human nature. Not many people other than Mother Teresa work for the good of humanity. Even though we all genuinely care about patients and want to be good doctors, the factor that might cause me to say, “Yes, I will stay late tonight to see that extra patient,” is that I need a new central air conditioning unit upstairs and it’s July in Texas. Socialism robs workers of their motivation. Period. That’s why it hasn’t work in any country, ever. However, completely unbridled capitalism raises the cost of care beyond what is necessary. We need to land in the middle. We also know that patients who receive entirely free care don’t do as well as those with some monetary investment. Patients need some skin in the game to help provide an incentive to lead healthier lives – which can take the form of either paying for some things, or being paid FOR certain behaviors. To anyone who thinks a completely socialized medical system is the answer, well, “Yer aff yer heid!”

In the meantime, I will always be grateful to the physicians, nurses and patients at The Western.

Here’s the English translation of an old Scottish poem:

If there is righteousness in the heart,
there will be beauty in the character.

If there is beauty in the character,
there will be harmony in the home.

If there is harmony in the home,
|there will be order in the nation.

If there is order in the nation,
there will be peace in the world.